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STRATEGY GUIDE 7

Community WorkApproaches

to address

Health Inequalities

THECOMMUNITYWORKERS

CO!OPERATIVE

�Health is a complete state of physical" mental and social well!being and not merely the absence of disease or infirmity###

health is a resource for everyday life" not the objective of living: itis a positive concept emphasising social and physical resources as

well as physical and mental capacity#The enjoyment of the highest standard of health is one of the

fundamental rights of every human being without distinction ofrace" religion" political belief" economic or social condition###�

(World Health Organisation)

Community Work Approaches to address Health Inequalities ! A Strategy Guide

Published by the Community Workers Co!operativeFirst Floor" Unit $Tuam Road CentreTuam RoadGalway

Telephone: %&% (')() **('%'Fax: %&% (')() **('%%E!mail: info@cwc#ieWeb: www#cwc#ie

ISBN: '!(&$'*+&!%!,

Copyright CWC ,''$Extracts from this publication may be reproduced in any form provided acknowledgement isgiven to the Community Workers Co!operative#

Supported by the Combat Poverty Agency Working Against PovertyGrants Scheme# The views expressed in this publication are those ofthe CWC and do not necessarily reflect the views of the CombatPoverty Agency#

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Community Workapproaches to address

Health Inequalities

Strategy Guide 7

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Community Workapproaches to addressHealth Inequalities

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Community Workers Co-operative

The Community Workers Co-operativeThe CWC is a national organisation whose members are committed to promotingand supporting community work as a means of achieving radical social change. Itwas formed in 1981 and it seeks to influence economic and social policies toensure the inclusion of, and to bring about equality of outcome for, those whoexperience exclusion and inequality. It works to contribute to the creation of a morejust and equal society through promoting a policy agenda drawn from local actionand experience.

The CWC services its membership through the provision of a range of informationand skills development resources. It has developed important campaigns, basedon member participation in relation to EU Structural Fund investments, the roleand organisation of the community sector, local government reform and the localsocial partnership arena, rural development, urban regeneration, educationaldisadvantage and gender issues. Members participate in regional networks thataddress regional issues and provide support mechanisms for members. They alsoparticipate in working issue-based sub-groups. These are:

A Community Sector subgroupAn Equality subgroupA Local Government subgroupA Global Development subgroupA Health Inequalities subgroupAn Educational Disadvantage subgroupA Rural subgroup.

AcknowledgmentsThe Community Workers Co-operative would like to thank Siobhan Lynam whoresearched and compiled this report. CWC also wishes to acknowledge thesupport and contributions of the following people and organisations:

• The Health Inequality Subgroup of the CWC• Stephanie Whyte, convenor of the Health Inequality Subgroup• Participants of the workshops• Contributors to the case-studies• Seán Regan, National Co-ordinator, CWC• Sharon Keane, Policy Worker, CWC

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Contents

Introduction and background to the Guide 4

The Health Debate 5Moving to a Social Model of Health

What Determines Good Health? 6

Responding to health inequalities in the community 13

How does Community Work differ from community based work? 15

Health Promotion and Community Work 16

A Framework for Understanding Inequality 18

The Policy Context supporting the Agenda of Community Work 22Acknowledging health as a human rightAcknowledging social and economic health determinantsPutting health at the centre of public policyRight to participateInitiatives to support Community Work approaches to addressing healthinequalities

The Objectives of Community Work 27in advancing the health and well-being of marginalised and excluded communities

Case Studies 32

1. The South Tyrone Empowerment Project 33A Community Development Project with a Health Agenda usingCommunity Work approaches to address health inequalities

2. A Voice for Older People 42A Community Work approach to working with Older People

3. Women’s Health Action, Cairde: 54Minority Ethnic Women Researching and Analysing their Needs

4. The Traveller Primary Health Care Project 62Using Community Work Approaches within a Model of Health Service Delivery to Marginalised & Disadvantaged Communities

Should Community Development Projects be engaged in the 75delivery of Health Services and Health Projects?

Facilitating Local Communities to Develop their Health Agenda 78

Best Practice Guidelines for Community-based Health Workers 79and other Health Workers within Statutory Agencies

Am I Adopting a Community Work Approach within the Health Project? 81A Checklist for health workers whose work is focused on local communities or communities of interest or who are employed in local community settings

How do we know that Community Involvement is successful? 82

AppendixesThe National Health Strategy 84

Useful Contacts 87

Bibliography 88

Introduction

The Community Workers Co-operative (CWC) is committed to the promotion ofCommunity Work as an intervention for social change. A key element of its workhas been, and continues to be, the active promotion and advancement of anequality agenda and the promotion of Community Work approaches to equalityissues within the various arenas within which the CWC operates at national,regional and local levels. One of the areas in which the CWC is involved is healthinequality.

In 2000, a number of members of the CWC came together to explore why healthissues are a concern for Community Work. Their work developed into establishinga Health Subgroup consisting of individual members of the CWC who are involvedin Community Development Work, and interested in Community Work approachesto addressing health inequality. Since that time the Subgroup has madesubmissions promoting Community Work approaches to addressing healthinequalities, including a submission to the NAPS Health Working Group. TheSubgroup has also been active in setting health priorities for national negotiations,and promoting Community Work in the National Health Strategy and the PrimaryCare Strategy through its membership of the Health Linkage Network. Over thecourse of this work, the Subgroup has identified a need for a strategy guide forlocally based Community Workers to support them to incorporate health into theirCommunity Work agenda, but also to support them to promote Community Workapproaches to addressing health inequalities at a local level.

The Strategy Guide is being produced by the CWC in order to highlight bestpractice and to form a basis of practice guidelines for locally based workersregarding Community Work and health. The production of the Strategy Guide isopportune at a time of developing interest in health inequalities, and at a timewhen a major restructuring of the health service is beginning to take place in linewith the commitments under the National Health Strategy 2001 Quality andFairness - a Health System for You. The Health Strategy puts a focus on health,not just on health services and acknowledges that peoples health is affected bysocio-economic, environmental and cultural factors. The Strategy whichemphasises the non-medical aspects of achieving full health and recognises theformal and informal role of the community in improving and sustaining social well-being in society, has ‘Strengthening Primary Care’ as one of its Frameworks forChange.

Health inequality refers to “the differences in the prevalence or incidence of healthproblems between individual people of higher and lower socio economic status”(World Health Organisation 1998).

Because of the prevailing medical definition of health, Community Workers andCommunity Development initiatives often do not recognise the health outcomesthat arise from Community Work. Community Workers are engaged in work thatboth promotes and produces good health, though they might not have a clearlydefined health agenda. They work with the most marginalised groups andcommunities. They work to empower and enable them to identify needs and todevelop confidence, knowledge and skills to work collectively to bring aboutchange in the central conditions of their lives. Their work is focused on buildinghealthy communities free from poverty, exclusion and discrimination. It is focusedon ensuring that marginalised groups are enabled to move from an experience ofpowerlessness to a sense of well-being and a realisation of their potential, and therealisation of their right to enjoy and fully benefit from the fruits of social andeconomic development.

This Strategy Guide is produced specifically to generate an analysis of CommunityWork approaches to health inequalities at local level and to share experiences ofwork to date through the presentation of case studies of Community Workapproaches to addressing health inequalities. The Strategy Guide is also intendedto help develop a focus on influencing policy with a view to achieving more healthycommunities. Four case studies have been chosen for inclusion in the Guide.These detailed case studies reflect the core elements of good practice from arange of different perspectives.

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The Health DebateMoving to a Social Model of Health

Health is a Community Work concern. Much Community Work being undertakenwith marginalised communities and groups has positive health outcomes. Indiscussions on health this is not usually acknowledged and the health outcomesof Community Work are not usually explored.

Given the crisis in the health system, it is understandable that a discussion abouthealth can quickly focus on funding and budgets and big strategies; on the longwaiting lists and waiting times for hospital procedures; the long waiting times inaccident and emergency departments; the centralisation of the system and itsinfrastructure for the treatment of illness and disease. Given the systemicinequalities which the Irish health system perpetuates, discussion can quicklyfocus on the two tier system of care; on the huge power of particular professionalswithin the hospital and health system; on the public funding of the private healthsystem and the extensive use of private beds in public hospitals. Frustration canalso focus discussion on the inefficiencies and bureaucracy in the public healthsystem which has been under-resourced for so many years.

Health problems, the symptoms of being unwell or ill are often medicalised,individualised and privatised in the doctor/consultant/patient relationship anddefined as problems that require the attention of experts, or that require a quick fixin the form of new and more powerful drugs produced and marketed by thepharmaceutical industry. Inequalities and problems that give rise to increasingstress, illness and lack of well being are accepted as part of everyday life. Starkinequalities, including the fact that mortality rates in the lowest occupational classare 100-200% higher than in the highest occupational class for all major causes ofdeath, are somehow considered normal in Irish society.

Furthermore, attempts to make sense of how the health system works is frustratedby a knowledge deficit about its structures, and about how it is organised andoperated and the different processes and operational procedures within andacross the myriad of systems, boards and agencies that define the health service.The public health system is not focused on public health but on diseasemanagement. Health promotion, which was given much momentum with thecardiovascular disease strategy and the development and expansion of healthpromotion units in each of the health board areas, is often mistakenly perceivedas a limited concept, as a non-smoking campaign or as a campaign to get peopleto do more exercise or to change dietary habits and reduce fat intake in order tohave more ‘happy’ hearts.

The social, economic, political and cultural systems and processes in Irish society,and the inequalities that these systems generate and reinforce, have until recently,been neglected in discussions of health and in the health debate. The factors thatcause poor health and health inequalities are complex and interrelated, but it isproven that people who are poor, who are disadvantaged and socially excluded,have the poorest health and die younger than those who are well off and canchoose their lifestyle and living environment. It is therefore important forCommunity Workers to develop an analysis of inequality, to understand howinequality is generated and sustained, how inequality impacts on peoples healthso that they can contribute to the vision and strategies for a healthier more equalsociety, and to the development of institutions and processes and programmesthat will promote equality and greater health outcomes for the people with whomthey work.

We will look at this in section 3, but firstly we will look at what determines goodhealth and examine what the World Health Organisation considers to be the keydeterminants of health.

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What Determines Good Health?

In the context of Community Work and Community Development practice at local,regional and national level, we need to be ever mindful of the key determinants ofhealth and well-being, in particular, when we are:

• identifying and developing our analysis of health inequalities at local level,

• developing our health agenda within the Community Development project andthe community sector networks, and

• engaging in health partnerships with a view to negotiating real and meaningfulchange in the health status of marginalised communities.

The improvement in people’s health must be a major objective of social andeconomic development. Health policy cannot be isolated from other developmentpolicies. A focus on the link between health policy and other policy sectors suchas employment, income maintenance and social welfare, housing and educationis therefore crucial, in all efforts to promote and achieve better health. HealthImpact Assessment is an important tool in the health proofing process.

It is common practice to review a long list of determinants of health, such as:genetic and individual factors, lifestyles, environment, and the availability andeffectiveness of health services. Until the 1950s, it was generally believed thatmost of the dramatic increase in life expectancy seen in the Western World duringthe 19th and 20th centuries was due to improving medical care. Since then,however, it has become clear that while modern healthcare has been veryimportant in improving the health status of people, the majority of the improvementin life expectancy has been due to improved economic and social conditions.

The great differences in health status observed across countries and amonggroups within countries have highlighted the fact that all these determinants arelinked to social and economic factors that are at the core of political and societaldevelopment.

The World Health Organisation (WHO) in its European Health Report 2001 statesthat while genetic and lifestyle factors clearly affect an individual’s susceptibility todisease, their role in the differences in health at population level is much lessevident. Individual lifestyle and risk factors explain only a portion of variations inthe occurrence of disease. The WHO European Health Report also states that,“the failure of individually focused health services to achieve the goal of universalaccess to effective health services of reasonable quality will contribute tounnecessary suffering and morbidity, but there is little evidence to suggest that thisfailure contributes substantially to the gross imbalances in public health seenacross the European Region”.

World Health Organisation: Key Determinants of HealthMany factors combine to affect the health of individuals and communities.Whether people are healthy or not, is determined by their circumstances andenvironment. The determinants of health include:

• the social and economic environment,• the physical environment, and• the persons individual characteristics and behaviours

The WHO defines the following as the key determinants of health:

Wealthier members of society live longer and tend to be healthier while doing so!

The differences in healthstatus among the countries ofthe European Region havethrown into sharp focus"factors ! beyond healthservices" genetics andindividual lifestyles ! thataffect health at populationlevel# The evidence has beenmuch clearer that thedifferences in health status aresubstantially a manifestationof social" economic"environmental andinstitutional determinants#(WHO European HealthReport ,''))

• Poverty• Psychosocial factors• Education• Unemployment/Employment

• Housing• Transport• Gender

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Poverty - the single largest determinant of ill healthPoverty and ill health form a vicious circle, poverty being both a determinant ofpoor health and a potential consequence of it. Whether defined by income, socio-economic status, living conditions or educational level, poverty is the single largestdeterminant of ill health.

Living in poverty is associated with lower life expectancy, high infant mortality, poorreproductive health, a higher risk of contracting infectious diseases (notablytuberculosis and HIV infection), higher rates of tobacco, alcohol and drug use, ahigher prevalence of noncommunicable diseases, depression, suicide, anti-socialbehaviour and violence and increased exposure to environmental risks. Evidencefor these associations is provided and outlined in the report Poverty and Health:evidence and action in WHO’s European Region1.

The WHO report cites particular groups at risk of poverty i.e. the unemployed, theurban poor, ethnic minorities and homeless people.

In the United Nations 2001 World Development Report, Ireland rated secondbottom in its record on poverty among the industrialised countries (16th of the 17).A look at some of the poverty statistics in Ireland give clear indications of those atrisk of ill health in Irish society.

• 65% of lone parents are below the poverty line2.

• 54% of households headed by an ill or disabled person are living below the60% median3. The average risk for consistent poverty is 22%4

• The proportion of elderly people living below the poverty line rose from 10% to30% between 1994-19985. Between 1994 and 2000 the risk of poverty forthose aged 65 and over rose from 6% to 43%6.

• In developed countries according to the WHO7, health is more related torelative rather than absolute poverty. An analysis of the taxation policies of theIrish government over 1987-99, reveal that budgets boosted the incomes ofthe richest one-third by 18% but the poorest one-third by only 4%. For the top20%, incomes rose 19% but for the bottom 20% they declined minus 1.2%.Such policies also work to reproduce the unequal distribution of resources andpass privilege from one generation to another.

• Ireland has the second highest rate of child poverty in the EU.

• The official figures for homelessness doubled between 1996 and 1999 (At5,234 the 1999 figure is considered a vast underestimate by NGOs workingwith homeless people). The poverty associated with homelessness hasalarming consequences in terms of overall mortality, prevalence of chronicrespiratory diseases, mental ill health and alcohol and drug dependence.

• There is growing poverty amongst ethnic minority communities.

) Poverty and Health: evidence and action in WHO�s European Region# Copenhagen"WHO Regional Office for Europe" ,'')

, Rights and Justice Work in Ireland: A new baseline# Brian Harvey ,'',# The RowntreeCharitable Trust

% Living in Ireland Survey# ESRI ,'''$ ibid#& Income" Deprivation and Well!being among Older Irish People# ESRI )(((+ Combat Poverty Agency Poverty Briefing No )%" ,''%* European Health Report ,'', WHO- Report of the Working Group on the National Anti!Poverty Strategy and Health

,'')# Institute of Public Health

In Ireland the gap in healthbetween rich and poor is

substantial# Mortality rates inthe lowest socio!economic

groups are over )''. higherthan in the highest socio!

economic groups for all majorcauses of death#

(Report of the Working Groupon the National Anti!Poverty

Strategy and Health ,'')-)

In both North and South" theall causes mortality rate in thelowest occupational class was)''.!,''. higher than the

rate in the highestoccupational class#

(Inequalities in Mortality)(-(!)((-# Institute of PublicHealth in Ireland# May ,''))

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Psychosocial FactorsLow self esteem, anxiety, insecurity, social isolation, lack of control over work orhome life produce stress. Psychosocial stress is increasingly recognised as a keyfactor in a number of conditions, including heart problems and hypertension,alcoholic psychosis, neurosis, homicide, suicide, accidents, ulcers and cirrhosis ofthe liver. According to WHO these tend to increase in importance in countriesundergoing accelerated social and economic transitions that are not adequatelysupported by social policy.

According to the National Economic and Social Forum (NESF) there are“increasing inequalities of outcome between social classes, between othermarginalised and more powerful groups, between the disabled and the non-disabled, between Travellers and settled people. New pockets of inequality havealso been created, especially among asylum seekers and refugees”9.

Although Ireland has undergone huge social and economic transitions in the lastdecade and has had the highest rate of economic growth in the EU throughout thelast decade, public expenditure is the lowest in Europe.

Factors which cause psychosocial stress include unanticipated rise inunemployment, employment turnover and job insecurity, erosion of the family,mounting distress, migration and rising social stratification. In Ireland,unemployment and job security may have not been perceived as highly significantfactors in relation to psychosocial stress until the restructuring of the economyover the past two years with consequential lay-offs, redundancies and a rise inunemployment. However erosion of the family, mounting distress, migration andrising social stratification have all been highly significant in an Irish context. Inrelation to rising social stratification in Ireland:

• The richest 20% earn six times as much as the poorest 20%. This is twice theratio of the best performing OECD country, Finland, and 20% worse than theEU average10.

• The income gap between the richest and the poorest has been widening

• From 1994-2000 the numbers experiencing income poverty increased from16% to 22% in the percentage below a central relative income poverty line of60% of median income11.

• 35.17% of the unemployed in 2000 were long-term unemployed, typically menover 40 who have been without work for a very long time12.

According to the WHO, the positive and negative impacts of social and economicpolicies on social capital, social networks and social cohesion need to be closelymonitored, as there is increasing evidence that such issues can have a protectiveor destructive effect on population health.

( A Strategic Policy Framework for Equality Issues" Forum Report No ,%# NESF March,'',

)' UNDP World Development Report ,'',)) Combat Poverty Agency# Poverty Briefing No )%" ,''%), Irish Congress of Trade Unions

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EducationEducation is an important determinant of health. According to the World HealthOrganisation (WHO), educational levels produce a gradient in mortality (death)and morbidity (illness and disease) similar to that produced by income.

• What is most disturbing in the available research is the extent to which socialclass of origin is so strongly related to the participation and performance of achild within the Irish education system ....substantial class differentials ....despite the overall increase in participation rates (NESF). The percentage ofstudents who left school without qualifications, 9.1%, contrasts with less than1% from the higher professional, lower professional and salaried employees13.

• Approximately 47% of lone parents has no formal education or primary levelonly. The lack of affordable accessible and flexible childcare means that loneparents can make very limited choices regarding education and training. 65%of lone parents live below the poverty line and feel hopelessness due to beingstuck in a poverty trap. The participation rate of Irish lone mothers in the labourforce is the lowest in the EU. Private childcare costs on average 20% of theaverage industrial wage compared to 8% in the EU.

• The material and cultural resources of a family have a major influence on achild’s educational attainment. 14% of the children of unskilled manualworkers attend college compared to 89% of the children of professionals.Children who attain higher levels of education or technical training have muchbetter chances in health, as well as in occupation and income.

Educational attainment is a more powerful predictor of differences in mortalitythan income inequality.

(British Medical Journal 2001)

Employment / UnemploymentAmongst employed people, there is a clear association between the grade ofemployment on the one hand and the morbidity (including rates of absence due toillness) on the other. The relationship remains when adjustment is made for factorssuch as level of education and tenure of housing. According to the WHO it seemsto be explained by higher levels of control, challenge and support enjoyed inhigher grades of work.

Both unemployment and work insecurity have detrimental effects on health,increasing the risk of psychological and physical disorders and suicide.Unemployment as a cause of poverty and ill health was a major issue through the1980s and early 1990s and is now again on the increase. The impact ofunemployment and poverty on young people is of particular importance, in view ofits association with health and social problems such as violence, suicide andsubstance misuse. According to the WHO, in the younger age groups, workinsecurity is associated with poor health, irrespective of any relationship betweensocial class and unemployment. The methods through which these trends affecthealth and well-being are complex and difficult to disentangle. Nevertheless thereis little doubt that they are related to various kinds of health risk and damage anda high incidence of psychological and mental health problems.

)% NESF Report No ,$ on Early School Leavers

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Housing / AccommodationThe housing environment is one of the main settings that affect human health. Thequality of housing plays a decisive role in the health status of residents, directly orindirectly.

• In 1999, 14% of Irish homes for older people lacked either a bathroom/shower,indoor flush toilet or hot water. When it came to older people living alone, 19%of homes lacked these amenities, the second worst record in the EU.

• 48,000 people are on the housing waiting list14. At the current rate of builds bythe local authorities, it will take 12 years to clear the housing waiting list15.

• Exacerbated by the housing crisis, the official homeless figure of 5,235 lastpublished in 1999 was double that of 199616. 75% of homeless people havemental health problems17.

• There were 939 Traveller families on the roadside at the end of 200218 withoutbasic facilities including sanitation and running water. Traveller infant mortalityrates are three times higher than the national rate. Traveller men live onaverage 10 years less than settled men and Traveller women live an average12 years less than settled women. Traveller health problems are linked to theirsocial and economic exclusion exacerbated by issues of appropriateaccommodation provision.

• Panel block buildings and high rise flats were constructed between the 1960sand the 1980s to meet housing needs. The poor living conditions inprefabricated buildings, caused by outdated construction methods and a lackof maintenance, have posed and continue to pose major problems in manyareas and also represent an unevaluated health risk. While regenerationprojects are currently underway in a number of areas, families still live wheresuch accommodation was constructed. The vast majority of newly constructedbuildings in large housing estates were built according to a fixed constructionpattern.

There is currently no policy by which housing investment is ‘indexed’ with healthgain. In the field of housing, the ‘economic’ and ‘engineering’ issues, rather thanthe health aspects have prevailed in the decision-making process. There aresignificant gaps in knowledge in the area of housing and health, and research hasnot focused on integrated approaches that deal with housing and health in aholistic way, or on acceptable approaches for risk assessment.

)$ Quarterly Bulletin of Housing Statistics" September ,'',)& Prof# John Monaghan" Secretary St Vincent de Paul Society" November ,''%)+ Department of the Environment Homelessness Survey)* Mental Illness ! The Neglected Quarter Amnesty International ,''%)- Department of the Environment and Local Government" Traveller Accommodation

Unit

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TransportThe accessibility, affordability and suitability of transport systems are key factorsthat have an impact on people’s health and well-being. Transport policy includinginvestment in public transport, has a significant impact on health and well-being,both positive and negative.

• Health gains can include increased opportunities for physical activity, throughsafe walking and cycling, as well as access to employment opportunities,education, health care and recreation.

• Health losses can include higher accident rates, more air pollution and noise,the isolation of and the separation of communities that are not serviced bypublic transport, most especially those communities that are already sociallyan economically marginalised. Health losses can also include more sedentarylifestyles.

• Vulnerable groups and those socially and economically marginalised andexcluded in both urban and rural areas, the elderly and children, tend to be themost severely affected by under investment in public transport.

• People with disabilities are excluded from accessing a range of services,development opportunities and employment opportunities due to a lack ofaccessible transport.

Health impact assessments should be undertaken in relation to transport planningand design. An integrated multisectoral approach involving all the relevantauthorities and stakeholders needs to be employed, and more attention paid tohealth considerations in decisions on transport and land use.

Health Impact Assessment (HIA) of all public policy must be introduced. In theEU, legislation under the Amsterdam Treaty makes provision for HIA in policymaking. The new Public Health Action Programme will facilitate the developmentof HIA across the EU.

HIA is a combination of procedures, methods and tools by which a policy,programme or project may be judged as to its potential effects on the health of apopulation and the distribution of those effects within the population (WHO 1994).HIA of non-health policies are increasingly seen as a tool to facilitate cross-sectoral action, and as a means to promote health and reduce inequalities.

The introduction of HIA will impact on the role of the health sector and othersectors, including local authorities and government departments. It involves amore proactive role with sectors promoting health as part of their policy andaddressing how the issue of HIA fits into their strategic planning cycle.

Age" sex" and hereditarycharacteristics inherited from

parents are the basicdeterminants of health status#

These are factors over whichindividuals have no control#

However an analysis of social"economic" environmental and

cultural factors that determinehealth and well!being give us

an understanding of the causeof health inequalities#

(World Health Organisation)

GenderGender has been recognised as a determinant of health, and gender inequalitycontributes to the risk of ill health.

Major differences exist with regard to the roles and status of women.

• In Sweden the proportion of women in government is about 50%, in Ireland theproportion of women in government is 13%. The percentage of women electedto the Dáil rose by 1% in the 10 years from 1992-2002.

• The number of women appointed to the Cabinet decreased by 7% for thecurrent government, while the number of women appointed as Ministers ofState decreased by 11%.

• Women’s representation on Health Boards ranges from 10% in the NorthEastern Health Board (3 women 27 men) to 30% on the South Western HealthBoard (7 women 16 men)19.

• Women are over-represented amongst the poor.

• Women’s average industrial hourly earnings are on average only 70% ofmen’s earnings. The gender pay gap crosses all sectors in the Irish economy20.

Gender roles may determine different patterns of disease in women and men,varying types of behaviour in seeking health care and varying responses byservice providers and researchers.

There are gender differences in health that have a biological basis, and there aresocio-economic factors that affect the magnitude of these differences.

Women live longer than men, but the burden of work at home and in the workplacetakes a heavy toll in terms of morbidity. Women are more likely than men to sufferfrom depression and anxiety. On the other hand men are more prone to accidents.

Differences between and amongst women that include socio-economic status,ethnicity, sexual orientation, responsibility for dependants, require consideration ofneed and appropriate responses and efficient interventions in health promotionand protection.

There is a developing knowledge base that relates disease patterns to theorganisation of society and the way it invests in its human development. Healthpolicies need to aim at reducing the overall burden of disadvantage. In attemptingto reduce health inequalities and create better conditions for population health,health policy cannot be isolated from other development policies. Thus the linkbetween health policy and other policy sectors such as employment, incomemaintenance and social welfare, housing and education is crucial in all Europeanmember States.(European Health Report 2002, World Health Organisation)

Income, Income Distribution and Social Status:Research indicates that income and social status is the single most importantdeterminant of health. Studies show that health status improves at each step upthe income and social hierarchy. In addition, societies which are reasonablyprosperous and have an equitable distribution of wealth have the healthiestpopulations, regardless of the amount they spend on health care.(The Population Health Template, Health Canada Population and Public Health BranchStrategic Policy Directorate July 2001)

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)( Irish Politics ! Jobs for the Boys# National Women�s Council of Ireland# ,'',,' Study of the Gender Pay Gap at Sectoral Level in Ireland" prepared for the PPF

Consultative Group on Male/Female Wage Differentials# INDECON InternationalEconomic Consultants ,'',

Responding to Health Inequalities in theCommunity - Responses from the StateIn recent years we have seen an increase in statutory agency delivery of care andservices from a base or centre in the local community. The Health (Amendment)(No 3) Act 1996 confers a statutory obligation on health boards to develop “healthpromotion programmes having regard to the needs of people residing in itsfunctional area and the policies and objectives of the Minister in relation to healthpromotion generally”.

The policies and objectives of the Minister and government are outlined in theNational Health Promotion Strategy 2000-2005 which defined health promotion as“making the healthier choice the easier choice or the process of enabling peopleto increase control over and to improve their health”. The emphasis is on enablingindividuals to take more responsibility for their health.

The Strategy outlines the Minister’s five chosen settings for health promotion.These are schools and colleges; youth sector; community; workplace; and healthservices. Within the community setting “the strategic aim is to support thedevelopment and implementation of community-based approaches”. The topicsprioritised for health promotion initiatives and activity are positive mental health;being smoke free; eating well; good oral health; sensible drinking; avoiding drugmisuse; being more active; safety and injury prevention; sexual health. A strategicaim and the specific objectives to be achieved by the health promotion strategyare set out under each topic.

It is the responsibility of the health promotion departments in each of the healthboards to plan, implement and evaluate at a regional level the objectives. Tosuccessfully implement the strategy, there has been an increase in the number ofprofessionals employed in the health promotion units. Existing regional healthpromotion structures in all of the ten health boards have been developed andstrengthened.

Community based Health Programmes, Health Promotion Projects, HealthyLifestyles Projects, Health Education Programmes, Nutrition Initiatives targetingDisadvantaged Groups, Feeling Fruity Projects, Healthy Eating Projects, HealthyCommunities Projects, Health Action Zones are increasingly being conceived anddeveloped, with the health promotion and health related activity targeted andfocused on a defined geographic community or town, or located and based in alocal community setting.

A number of local communities have themselves initiated discussion and researchon local health needs as part of a regeneration strategy.

Under the National Health Strategy Quality and Fairness, A Health Strategy forYou ten demonstration Primary Care Units have been established by the HealthBoards. These Primary Care Units are required to consult with the localcommunity in relation to the piloting and development of the Primary CareProgramme. This experience is intended to influence and present a model ofcommunity participation in the implementation of the National Health Strategy.There are also Drug Task Force initiatives, self-help groups, numerous projectsthat work with individuals within communities that involve the provision ofeducation, information and advice on health matters, there are interagencyinitiatives, and there are collaborations between various agencies and local actorsin order to enhance and ensure better health service delivery at local level.

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Community Developmentwork requires specific skills"

understanding and experienceand it is not an �add on" to

other duties and tasks ofhealth service workers#

(Community Development andthe Tyne and Wear Health

Action Zone)

The term ‘Community Development’ is often loosely used in relation to health workat local level and used in a way that promotes confusion. A number of the newcommunity based initiatives in the health area, similar to those defined above, areoften mistakenly defined as Community Development. The term ‘CommunityDevelopment’ is often used to merely define the intersectoral approach beingadopted at local level to address health issues. It is sometimes used to define theprocess or an expected outcome of a health initiative, or indeed to describeelements in the approach that is being used in the health work being undertaken.Sometimes Community Development is loosely applied to a whole range of healthservice practice where a health service agenda is being progressed.

It is important to define Community Work and Community Development from theoutset. Being clear about the definition of Community Work that underpins anapproach to tackling health inequalities is crucial to long term outcomes andprogress.

Community Development is about actively enabling people to enhance theircapacity to play a role in shaping the society of which they are a part. It workstowards enabling groups and communities to articulate needs and viewpoints, towork collectively to influence the processes that structure their everyday lives andto take part in collective action that will contribute to making real, positive andlasting change. Given that the opportunity and the resources required toparticipate fully in society are more open to some groups and individuals, thepriority, for those engaged in local social and economic development andCommunity Work, is to work with the most marginalised groups and communities- those experiencing poverty, inequality and social, cultural and economicexclusion21.

Community Work is a developmental activity composed of both task andprocess. The task is the achievement of social change linked to equality and socialjustice, and the process is the application of the principles of participation,empowerment and collective decision-making in a structured and co-ordinatedway.Community Work is focused on:

• the creation of opportunities which facilitate a social analysis of needs andappropriate responses;

• the development and delivery of actions which elevate the socially excluded;

• enabling groups and communities to develop consciousness, analysis andunderstanding of the issues to be addressed so that they can take part incollective action

• the strengthening of organisational capability which will facilitate excludedgroups and communities to impact on local and national policy.

This requires dedicated staff with a specific remit to work with named groups.

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Community Workers andCommunity DevelopmentProjects are already promotingand producing health and well!being within marginalisedcommunities#Even though manyCommunity Development andEquality Projects may yet haveto consciously develop theirhealth agenda" the causes anddeterminants of ill health andHealth Inequalities are alreadya focus of much CommunityWork and CommunityDevelopment#

,) Community Development Brochure" ADM )((%

How does Community Work differ fromCommunity Based Work?Community Work differs from community ‘based’ work such as service delivery,health promotion projects, local development, community-based inter-sectoralhealth partnerships, in that it is consciously, actively and specifically focused onbringing about social change in favour of those most marginalised or excluded insociety, both geographic communities and communities of interest, and enablingthem to address the social, political and economic causes of this marginalisation.It is concerned with challenging existing power relations and addressing powerinequalities.

Community Work is premised on the belief that inequality is structured and isgenerated in the major institutions and systems that have been established toorganise society, institutions and systems that are changeable and changing,including the health system, the education system, the economic system.

Community Work principlesWhy community work produces health and well-being...Community work

• is collective. It is based on working with and supporting groups of people,enabling them to develop their consciousness, analysis and understanding ofthe issues to be addressed so that they can take part in collective action.People enduring multiple disadvantages tend to experience them as personaland disabling. The collective and participatory approach of community workprovide opportunities to recognise commonality in problems and themotivation and opportunity to affect change. Through collective activity peoplecome to see common problems as objective and open to remedy.

• is participatory. Its focus is to socially include, it advocates and claims theright of excluded groups to come in from the margins. It values, stimulates andencourages marginalised groups to become involved in defining their realneeds and developing responses to the problems they experience. In thiscollective process individuals overcome demoralisation, low self esteem,social isolation.

• is empowering. It provides opportunities for people to become critical,creative, free, active human beings allowing and enabling them to take morecontrol of the direction of their lives, their community and their environment.

• is about power-sharing. It aims to effect a sharing of power to createstructures that provide genuine participation and involvement. It is a processbased on mutual respect and equal and genuine partnership between all thoseinvolved to enable a sharing of talents, experience and expertise.

• is concerned with both the task and the process of development.Importance is attached to the task which is social change linked to socialjustice and equality and the process by which change is achieved, promotinga collective process which is inclusive.

• is committed to developing innovative and creative approaches. It aimsto address the economic and social problems that arise from deprivation. Itrecognises that with adequate resourcing a community work approach canunlock a huge reservoir of talent and ideas that can contribute to socialchange. It seeks in a dynamic way to test new approaches which ensure theinvolvement of local communities.

• is about gaining concrete improvements in the quality of life ofmarginalised communities. These improvements reflect real needs asidentified by these communities themselves.

• is involved in devising strategies which confront prejudice, racism,sexism, and discrimination on the basis of class, socio-economic status,gender, disability, age, ethnicity, skin colour, nationality, responsibility fordependants, marital status, sexual orientation.

• is about celebrating achievements, showing off, sharing lessons andpromoting good practice. Its achievements can often be forgotten orattributed to public authorities, when new amenities are created or existingones saved through public pressure or when new groups successfully engagein partnership arrangements after a lot of pre-development work and capacitybuilding.

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Community Work consists of an analysis of social and economic situations andcollective work for social change. It should lead to improved individualcircumstances, but the target is positive change for the whole group. It is based ona set of principles that involve not only building capacity to participate, but also thedevelopment of consciousness, analysis and understanding of the issues to beaddressed. It goes beyond consultation to participation and focuses on how thingsget done as well as on what is to be done, in ways that are empowering for allconcerned, particularly the target groups. It is primarily concerned with thepromotion of a just, equal and inclusive society at local, national and internationallevels.

Health Promotion and Community Work“Health promotion is now a world wide movement concerned with improvingindividual and population health. It is now considered an umbrella term for a widerange of activities that seek to enhance physical, mental and social well-being andprevent ill-health. It is increasingly referred to as a mechanism for delivering on ahealth improvement agenda”22.

Health promotion, guided by the principles of the Ottawa Charter for HealthPromotion (WHO 1996) offers possibilities to promote Community Workapproaches to health inequalities and to address the social and economicdeterminants of health and well-being and the causes of health inequalities. (Fordetails of the Ottawa Charter, see the section in the Guide on ‘The Policy Contextthat Supports the Community Work Agenda’, p. 22)

While Community Work principles underpin much health promotion activity,concern exists that within the broader policy context, blame for health choices istoo often focused on the individual and not on the broader situation of poverty,inequality and social exclusion.

The National Health Promotion Strategy poses particular challenges. The strategicemphasis in this Strategy is on “how we as individuals influence our own health”.The Strategy prioritises particular topics on which health promotion should befocused. Furthermore it suggests a particular emphasis on the monitoring of healthpromotion activity. These core elements of the Strategy all pose challenges forcommunity health workers in the health promotion field, who want to adopt thesocial model of health and to address in their work practice the social andeconomic determinants of health and well-being and the causes of healthinequalities. If health status is viewed in single issue terms, then the structuralcauses of health inequalities are in danger of being ignored.

The Ottawa Charter mandates those engaged in health promotion to work from thesocial model of health and to engage in action to build healthy public policy whichwould include legislation, fiscal measures, taxation and organisational change.They are also mandated to strengthen community action in setting priorities,making decisions, planning strategies and implementing them to achieve betterhealth. There is a general welcoming of health promotion initiatives and theirusefulness in placing emphasis on promoting health gain.

The National Health Promotion Strategy does offer opportunities for effectivecommunity based work to address health inequalities. In particular, it clearly offersand defines an important role for community based health workers in addressingstructural inequalities and in influencing policy development when it states that“The challenge for health promotion is to bring about health and social gain in acomprehensive and equitable manner by responding to the evidence presentedfrom social, economic and environmental factors, lifestyle behaviour and illnesspatterns. This can only be achieved via an inter-sectoral and multi-disciplinaryapproach”23.

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,, National Health Promotion Strategy ,'''!,''& p# ++ Department of Health andChildren July ,'''

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Structural Inequalityrefers to the inequality which is structured into and is generated, sustained andreproduced by the dominant institutions and systems that we have established toorganise our society e.g. economic system with its free market, the welfaresystem, the two-tier health system, the education system, representativegovernment, the mass communications systems, and by the influence that theseinstitutions have on peoples attitudes, preferences and prospects.

The persistence of inequalities through the generations is an indictment of theeducational system. Education is often presented as a neutral exercise, givingcredentials to those who have the greatest ability and work hardest. Thequestion needs to be asked:Why is it that children who are bright, with a range of different intelligences, whohave great ability and enthusiasm but who grow up in impoverished families, infamilies who have no choice but to live in poor housing or accommodation, whohave poor food and diet, who have no choice but to go to under-resourcedschools, with their fair share of disruptive pupils, primary schools with the highestpupil-teacher ratio in the OECD, why do they have a minimal chance of escapingvia education into better paid employment? Why is it more likely that they willhave a life of poverty and insecurity, ill health and poor quality of life not unliketheir parents?

This is in contrast to the children who grow up surrounded by all the comfortsthat money can buy, who are educated in ‘good’ schools with low pupil teacherratios, or increasingly in private schools that are highly subsidised by the publiceducation budget, whose parents can buy additional educational anddevelopment opportunities, extra curricular activities, summer schools, grindschools, travel, student exchanges and who can use their contacts, their socialnetworks and know-how to help their children into successful and well-paidcareers.

Community Work is an essential methodology for bringing about a more equal, justand sustainable society and for any strategy or programme aimed at achievingthese goals to be effective. The Case Studies presented in this Strategy Guide arecase studies of Community Work and Community Work as a methodology inaddressing health inequalities.

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A Framework for Understanding InequalityThe National Economic and Social Forum (NESF) which brings together the socialpartners and the state has given us a framework for understanding inequality24.

Inequality is experienced and evident in the:• Economic,• Political,• Socio-cultural,• Human interaction (caring) spheres of human activity.

The systems and structures within these spheres generate, sustain and reinforceinequality which impact on the health and well-being of communities. Of coursewhat happens in one of these arenas has an impact on others, they are interlinked.Inequality is also generated and reinforced through the connections between andacross these arenas.

It is important for Community Workers and Community Activists to develop theiranalysis of inequality and the causes of inequality in each of these different butinterdependent contexts. Community Workers must understand impacts on healthand well-being in order to come up with a vision and the strategies for a moreequal society, including institutions and systems that will promote equality andgreater health and well-being.

Policy actions are necessary in these arenas if health inequalities are to beseriously addressed.

The Economic SphereEconomic injustice refers primarily to the unequal distribution of materialresources and inequality in their ownership and control.

There are substantive wealth and income disparities and a sizeable number ofpeople living in poverty. Ireland ranked second bottom in its record on poverty inthe UN World Development Report 2002 (16th of the 17 industrialised countries).There is little or no attempt to change the structures that enable and generate theinequalities. There is a widening of the gap between the rich and the poor sincethe 1970s.

For the past decade Ireland has had the fastest growing economy in the EU.Gross Domestic Product25 (GDP) per head does have a significantly positivecorrelation with life expectancy, however this relationship works mainly through theimpact of GDP on (a) the incomes of the poor, and (b) public expenditure,particularly in health care26. Much therefore depends on how economic wealth isdistributed and organised. One of the most striking features of the Irish taxationsystem when compared to other countries is that there is no wealth tax or propertytax in Ireland. Ireland has one of the most lenient capital tax regimes in Europe27.

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,$ NESF" A Strategic Policy Framework for Equality Issues Forum Report No ,%" ,'',#The Equality Studies Centre in UCD has for the past number of years activelycontributed to developing a framework for thinking about equality and hascontributed substantially to advancing a Strategic Policy Framework for EqualityIssues# The Framework has been adopted by the NESF and the Equality Authorityamongst others#

,& Gross Domestic Product refers to the total output produced in the Irish economyregardless of the residence of the owners of production# It includes output byforeign!owned producers located in Ireland" but does not include output by Irish!owned producers located abroad#

,+ Wilkinson" R#G# Unhealthy Societies: The Afflictions of Inequalities# Routledge" )((+,* NESF" A Strategic Policy Framework for Equality Issues# Forum Report No ,%" ,'',

There has been no commitment in the past number of budgets to the introductionof progressive tax policies that could be employed to redistribute the excesswealth of some citizens into programmes that benefit the others. An analysis oftaxation policies over 1987-99 reveal that budgets boosted incomes of the richestone third by 18%, but the poorest one-third by only 4%. For the top 20%, incomesrose 19% but for the bottom 20%, incomes declined by 1.2%.

In Ireland, public expenditure is the lowest in Europe. There is evidence that healthspending in the private sector in Ireland is above the EU average, while spendingin the public sector continues to lag behind the EU average28. There is alsoevidence that unless medical care is targeted appropriately, that it may contributeto widening of differences between socio-economic groups because of a thegreater capacity of well off people to obtain medical care. There are many kinds ofresources, not just income and wealth, but also family connections, educationalcredentials, access to health services, environmental conditions.

Political SpherePolitical inequality occurs when and wherever power is enacted e.g. in decision-making, including policy-making, and in power structures generally. It can takedifferent forms e.g. political exclusion, political marginalisation, politicaltrivialisation or political mis-representation (Baker 1998).

Often people feel that they can vote for those that will govern them but rarely forthe policies by which they will be governed. The equal right to vote does notguarantee an equality of influence on political decisions, for the resources we bringto politics, (money contacts, education, time) disproportionately favour certaingroups, while the economic and bureaucratic power of non-elected bodies, e.g.private companies, and the civil service, is such that major decisions are made ontheir terms.

It is assumed that through the party system men can represent all women’s needsand interests, that middle class people can represent the interests of working classpeople, that settled white people can represent the needs, interests and concernsof Travellers and other minority ethnic groups.

Those who are marginalised in our political system are subordinated and highlydependent on services over which they exercise little choice or control, such ashousing, health, education, or welfare.

Currently, Health Board directors are political appointees, VEC members arepolitical appointees and it is highly likely that the members of the schools boardsof management are the most vociferous, settled and well off parents of the schoolgoing children.

The farther you are from the decision-making the less chance you have to haveyour needs and interests heard and accommodated. The democratic participationof marginalised groups needs to be strengthened both inside and outside of formaldecision-making structures, in a way that is likely to be comfortable to existingpower holders. Political equality is about empowering those currently marginalisedin terms of political influence (NESF29).

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Currently health goes withwealth and the redistribution

of income and resources seemsto be the best route to

redistribution of well!being"even it is not on the political

agenda#

,- OECD Health Data ,''',( NESF" A Strategic Policy Framework for Equality Issues# Forum Report No ,%" ,'',

Community work is about working with the most marginalised groups, thoseroutinely disparaged, and patronised, subjected to insult and violence. It is aboutenabling and allowing them to become critical, creative, free, active human beings,allowing and enabling them to engage in collective action so that they can takemore control over the direction of their lives, their community and theirenvironment in all its forms.

This is a claim for a political voice so that those currently marginalised can beinvolved in devising the appropriate policies for change, for their recognition asmembers of a particular group, political actors in their own right with their ownspecific concerns, insights and objectives. In this process they do not seethemselves or refuse to be treated as a ‘problem’ for other social groups toresolve. In the process they are enabled to shake off the external perceptions ofwhat they are or ought to be and claim the right to define themselves. This is aprofoundly democratic vision. People are seeking a place at the table, a chance toarticulate their own, possible different, perspectives and priorities and a guaranteethat they too will be acknowledged as equals.

Socio-Cultural SphereSocio-cultural injustices are injustices that are rooted in patterns of representation,interpretation and communication. They take the form of cultural domination,symbolic misrepresentation or non-recognition all which can lead to and result ina lack of respect.

The core concern here is with the mutual respect and recognition that is due to allmembers of society independent of their class or socio-economic background,their gender, their age, national or ethnic origin, their skin colour, their sexualorientation, their religious or political beliefs, their family status and responsibilityfor dependants, their marital status, their physical or mental capabilities.

Inequality of recognition is a failure or refusal to recognise certain sorts of peopleas our equals and perhaps more commonly, a tendency to view them throughdisparaging stereotypes or to refuse to recognise the legitimacy of their differentway of life. If your identity or your way of life is not recognised as of equal value tothat of others, this will be experienced as a form of oppression. It is another kindof inequality in which certain groups of people are treated as of lesser significancethan the rest. This has major negative health impacts. The effects accumulate andthe longer groups experience marginalisation and exclusion, the less likely theyare to enjoy good health in older years.

The manner in which politics, the economy, communications networks and the laware operated and organised are all significant in reinforcing or denying respect andrecognition. The right to acquire and enjoy property is considered legallyenforceable, but the right to have a roof over one’s head in the first place is not,all human rights are not equally regarded and equally enforceable.

The education system is one of the most powerful systems for cultural production,transmission and legitimisation. Yet it is still possible for most children to gothrough the Irish education system with little or no exposure to the experiences orpoints of view of Travellers, religious minorities, ethnic minorities or young peoplewith disabilities.

Cultural institutions and systems for cultural production including TV and printmedia regularly stereotype women, asylum seekers and refugees, Travellers, andminority ethnic groups.

Groups that are ignored, misrepresented, trivialised, or otherwise negativelyportrayed in institutions such as the media or education are generally not grantedpolitical acceptance in other social contexts. As a result they may be excludedfrom consultative arrangements, decision-making processes, or other relevantpolitical engagements.

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In promoting equality of recognition and respect, the objective is not that these‘different’ groups are tolerated, but that difference and diversity is acknowledgedand accommodated, and indeed celebrated. This will involve the affirmation andthe practical accommodation of difference and diversity in the development ofpolicies, practice and provisions. It also requires that structures, systems andinstitutions change to allow for, and accommodate the different norms, values,ways of living and needs. In this way real choices are offered that reflect and haverelevance to the various groups who currently experience inequality anddiscrimination.

Human InteractionInequalities arise in the emotional domains of human relations. The importance oflove/care/solidarity relations of human life are central to human development. Likeeconomic, political and socio-cultural relations, they relate to human existence andactivity over which the State exercises both direct and indirect controls, throughconstitutional and legislative provisions and policy measures. Although love, careand solidarity relations are sometimes defined as private matters, in policy terms,they are publicly regulated and facilitated and are, therefore, open to policychanges and developments30.

Inequalities in this sphere exist when a person is deprived of the emotionalnurturance they need to develop and / or maintain intimate, trusting, and solidarity-based human relationships.

The high levels of child poverty in Ireland which have clear implications forchildren’s emotional development and well-being, are echoed by specificinstances of neglect and an absence of state services. In 1999, Focus Irelandfound that between a third and two-thirds of children leaving care subsequentlybecame homeless.

People on the housing waiting lists, in B&Bs with no fixed abode, wander thestreets during the day with little chance of developing proper relations of love, careand solidarity, as individuals, as a family or community.

Those involuntarily institutionalised for reasons of mental illness or because of adisability may also lack opportunities to develop friendships, relationships ofintimacy or personal attachment or to develop friendships and bonds of solidarityin the context of their community.

The inequalities in the sphere of love, care and solidarity are well known to olderpeople and disabled people who have to leave friendship ties in their communitiesbecause of a lack of appropriate services and accommodation provision withintheir own geographic community, this is especially the case in rural areas.

A person’s social integration into a community can affect their health. Poor socialsupport, marginalisation and isolation can make people more vulnerable tophysical and emotional health problems. But high levels of trust, mutual respect,effective collaboration and strong personal support networks within communitiescan improve people’s health and well-being and protect against the effects ofpoverty and other trauma.

Promoting equality in the spheres of human solidarity and love involvesrecognising the complex ways and contexts in which deprivations can occur aswell as promoting conditions for a quality of life that includes intimacy, solidarity,trust and care.

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The Policy Context supporting the Agenda ofCommunity WorkThere is a very strong policy context which supports adapting community workapproaches to address health inequalities.

Acknowledging Health as a Human RightThe International Covenant on Economic, Social and Cultural Rights, alegally binding treaty that Ireland has ratified states: The State Parties to thepresent Covenant recognise the right of everyone to the enjoyment of the highestattainable standard of physical and mental health (Art. 12).

The International Committee which monitors the implementation by State parties31,have criticised Ireland for not adopting a human rights framework in the HealthStrategy 2001 Quality and Fairness - A Health System for You and haverecommended that they do so. Quality and Fairness - A Health System for Youmerely acknowledges equity as a principle i.e. that “everyone should have a fairopportunity to attain full health potential and, more pragmatically no-one should bedisadvantaged from achieving this potential, if it can be avoided” (p.17).Furthermore the International Committee has been highly critical of the fact thatthere is still not a common waiting list for treatment in publicly funded hospitalservices for publicly and privately insured patients. Private patients get preferentialtreatment in public hospitals and the committee strongly recommended that this bechanged.

The World Health Organisation states that Health is a complete state ofphysical, mental and social well-being and not merely the absence of disease orinfirmity ... The enjoyment of the highest standard of health is one of thefundamental rights of every human being without distinction of race, religion,political belief, economic or social condition ...

The Good Friday Agreement 1998 includes a commitment by the IrishGovernment to take steps to further the protection of human rights within itsjurisdiction. The agreement requires that the measures taken in Ireland will ensureat least an equivalent level of protection of human rights North and South.

Health is one of the areas for North/South co-operation under the Good FridayAgreement. Health is defined as a fundamental human right in Northern Ireland.The Health Strategy 2002 for N. Ireland, Investing for Health adopts the followingvalues:

• Health is a fundamental human right

• Policies should actively pursue equality of opportunity and promote socialinclusion

• Individuals and communities should be involved fully in decision-making onmatters relating to health;

• All citizens should have equal rights to health, and fair/equitable access tohealth services and health information according to their needs.

In addition, the social model of health and the health and well-being ofmarginalised communities is promoted in Northern Ireland, because there is aStatutory Duty imposed on public authorities (i.e. an imposed legal requirement)to promote equality and an enforceable duty to eliminate discriminatory structures,processes and actions. In carrying out its functions the public authority must havedue regard to the need to promote equality of opportunity and is obliged to preparean Equality Scheme setting out the equality impact assessment, monitoring andconsultation procedures with the groups that may be affected.

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and ratified the Covenant

All bodies operating under the Health umbrella must undertake an equality impactassessment of health strategies and resource allocations to ensure that theypromote equality and address any discrimination that might currently exist on thebasis of religious belief, political opinion, racial group, age, marital status, gender,sexual orientation, disability, responsibility for dependants. The demand of thecommunity sector is for at least the equivalent level of protection of human rightsNorth and South as is required by the Good Friday Agreement.

The Seventh Conference of European Health Ministers in Oslo, June 2003called on the Council of Europe to intensify its work on the social, ethical andhuman rights dimensions of health care and related services. The Ministersrequested the Council of Europe to propose measures aimed at reducinginequalities in access to high quality health care both within and betweencountries.

WHO and the Council of Europe affirmed their commitment to co-operation andthe tools provided by the World Health organisation can help the Council of Europeand its member states to assess how far health policies are consistent with humanrights.

Acknowledging Social and Economic Health DeterminantsThe World Health Organisation defines health as “a complete state of physical,mental and social well-being and not merely the absence of disease or infirmity...”According to the WHO “Age, sex, and hereditary characteristics inherited fromparents are the basic determinants of health status. These are factors over whichindividuals have no control. However an analysis of social, economic,environmental and cultural factors that determine health and well-being give us anunderstanding of the cause of health inequalities”.

Ottawa Charter for Health Promotion (WHO 1996)In 1978 the Declaration of Alma Ata (outlined in the introduction to the case studyon Traveller Primary Health Care Project on p. 62) was an important milestone inthe promotion of world health and provided the blueprint for ‘Primary Health Care’and ‘Health For All by the year 2000’. In 1986, the WHO held its first InternationalConference on Health Promotion in Ottawa, Canada and produced the OttawaCharter for Health Promotion. The charter builds on the Declaration of Alma Ataand calls for action on five fronts by:

• Building Healthy public policy

• Re-orienting the health services

• Creating supportive environments

• Strengthening Community Action

• Developing personal skills

Guided by the Charter, the practice of health promotion aims to developinnovative, practical approaches to promote health and well-being and to addresshealth issues.

The EU Public Health Programme was adopted in Dec. 2002 and runs fromJanuary 2003 - Dec. 2008. One of the three strands of action of this newProgramme is Health Determinants. It will concern itself with tackling determinantsof health at EU level and has prioritised analysing the situation and developingstrategies on social and economic health determinants in order to identify andcombat inequalities in health and to assess the impact of social and economicfactors on health. There will be an emphasis on involving stakeholders in theEuropean Health Forum and a key element of the work of the Programme will bethe support of initiatives exploring inequalities in health with a focus on reportingexperience and best practice and networking.

The National Health Promotion Strategy 2000-2005 highlights social, economicand environmental factors as the main determinants of health. ,%


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Health Strategy 2001 Quality and Fairness - a Health System for You puts afocus on health, not just on health services and acknowledges that peoples healthis affected by socio-economic, environmental and cultural factors. “People fromthe lower socio-economic groups suffer a disproportionate burden of ill health. Theequity principle recognises that social, environmental and economic factorsincluding deprivation, education, housing and nutrition affect both an individual’shealth status and his or her ability to access services” (p.18). The Strategyemphasises the non-medical aspects of achieving full health and recognises theformal and informal role of the community in improving and sustaining social well-being in society.

The National Anti-Poverty Strategy NAPincl (July 2001-June 2003) describesthe present situation of poverty and social exclusion in Ireland and the mainchallenges for poverty reduction and social inclusion and presents a nationalaction plan. It facilitates reviews every two years of national anti-poverty policieswithin the context of the NAPS 1997-2007. In relation to promoting health andwell-being, NAPincl is important as it highlights the past failure and current andfuture need, to acknowledge poverty as a major health determinant, and poorhealth as a major cause of poverty. It provides political sanction, as well as astrategic framework for the social model and broader, dynamic and positivedefinition of health. It provides the context for closer cross-sectoral collaborationaround the shared responsibilities for health. Health targets have been establishedwith a view to reducing the gap in health between rich and poor, promoting equityof access to health services and developing new ways of working to address themain factors which link poverty and ill health.

Putting Health at the Centre of Public PolicyAs part of the process of strategic management in Government Departments andOffices, each is now obliged to prepare a Strategy Statement covering a three yearperiod. It is an opportunity to consider how the organisation needs to respond interms of its structures, systems and resources to meet its goals. It also offers thepossibility for greater transparency and accountability in the implementation ofsocial policy. According to the Guidelines for Secretaries General and Heads ofOffice on the Preparation of Strategy Statements32 all relevant Departments shouldincorporate an explicit commitment to sustaining and improving health status inaccordance with Objective 1.2 of the National Health Strategy which considered ofprimary importance that the health of the population is at the centre of publicpolicy.

One of the strands of the Strategic Management Initiative (SMI) is QualityCustomer Service. Equality Diversity is one of the key principles underpinningQuality Customer Service. A support pack on Equality Diversity Aspects of QualityCustomer Service for the Civil and Public Service has been prepared by theEquality Authority.

Health Impact Assessment Guidelines are currently being developed on behalf ofthe Department of Health and Children by the Institute of Public Health. Work onthe development of HIA is being undertaken on an all-island basis.

The Implementation of the EU Strategic Environmental Assessment Directiveprovides another way to ensure that health impacts are carefully consideredacross all sectors. The Directive will require an assessment of certain plans andprogrammes which are likely to have significant effects on the environment. Thiswill include an assessment of the impacts on human health. The Directive must beimplemented by 2004.

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%, Delivering Better Government Guidelines for Secretaries General and Heads of Officeon the Preparation of Strategy Statements Department of the Taoiseach

The Right to Participate

The Alma Ata Declaration 1976 made participation a central feature of PrimaryHealth Care. It stated that people have the right and duty to participate individuallyand collectively in the planning and implementation of their health care.

The Harare Declaration of 1987 outlined community involvement in health as aprocess of direct public involvement in health systems, not only strengtheningpeople’s organisations and skills, but also reorienting political and health systemsto support such participation.

The Ottawa Charter for Health Promotion 1986 highlighted the importance ofstrengthening community action and empowering communities. According to theCharter, health promotion works through concrete and effective community actionin setting priorities, making decisions, planning strategies and implementing themto achieve better health. At the heart of the process is the empowerment ofcommunities, and their ownership of their own endeavours and destinies.

Health Strategy 2001 Quality and Fairness - a Health System for You,emphasises the non-medical aspects of achieving full health and recognises theformal and informal role of the community in improving and sustaining social well-being in society. The National Health Strategy contains a specific commitment tocommunity participation and states that “provision will be made for theparticipation of the community in decisions about the delivery of health andpersonal services” (Action 52).

Community Participation Guidelines (Health Board Executive 2002). Theguidelines can be used by all health service providers to ensure that “the principleof ‘people-centredness’ which is at the heart of the strategy becomes anincreasingly important feature of how we plan and deliver services”. Theguidelines define the term community participation as “A process by which peopleare enabled to become actively and genuinely involved in defining the issues ofconcern to them, in making decisions about factors that affect their lives informulating and implementing policies, in planning, developing and deliveringservices and in taking action to achieve change”.

Primary Care Strategy (recommendation 19) states that Mechanisms for activecommunity involvement in Primary Care Teams will be established: “Communityparticipation in primary care will be strengthened by encouraging and facilitatingthe involvement of local communities and voluntary groups in the planning anddelivery of primary care services. Consumer panels will be convened at regularintervals in each Health Board”.

Government White Paper ‘Supporting Voluntary Activity’ recognises the roleof Community Work and Community Work organisations - “An active Communityand Voluntary sector contributes to a democratic pluralist society, providesopportunities for the development of decentralised and participative structures andfosters a climate in which the quality of life can be enhanced for all”.

EU National Action Plan against Poverty and Social Exclusion (NAPSInc)agreed in Nice in 2002 has as one of its objectives “To promote, according tonational practice, the participation and self expression of people sufferingexclusion, in particular in regard to their situation and the policies and measuresaffecting them”.

United Nations Development Programme (UNDP) report OvercomingPoverty 2000 acknowledges that “The foundation of poverty reduction is selforganisation of the poor at the community level - the best antidote topowerlessness, a central source of poverty. Organised, the poor can influencelocal government and help hold it accountable. They can form coalitions with othersocial forces and build broader organisations to influence regional and nationalpolicy-making. What the poor most need, therefore, are resources to build theirorganisational capacity”.

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The term �communityparticipation� can be defined as�A process by which people are

enabled to become activelyand genuinely involved in

defining the issues of concernto them" in making decisions

about factors that affect theirlives in formulating and

implementing policies" inplanning" developing anddelivering services and intaking action to achieve

change�

(Community ParticipationGuidelines: Health Strategy

Implementation ProjectDecember ,''," p#%)

Initiatives to support Community Work Approaches toAddressing Health Inequalities

The Combat Poverty Agency, under its Strategic Plan 2002-2004 has developedwork to support disadvantaged communities to tackle health inequalities.Following on its consultations, and the findings and recommendations of a Round-table with community sector and local health interests, and recommendations inresearch paper, the Combat Poverty Agency launched its Building HealthyCommunities Programme at a national conference in Dublin in May 2003.Designed to support community participation in tackling Poverty and HealthInequalities, it is aimed at groups / organisations from the CommunityDevelopment / anti-poverty sector especially those who want to work with otherhealth interests. Funding for the Programme in 2003 is €150,000. Thirteeninitiatives have been grant aided in 2003 (individual grants to Community Groupswas not to exceed € 15,000).

The Building Healthy Communities Programme aims to:

• Promote the practice of Community Development in improving health and well-being outcomes for disadvantaged communities;

• Inform and support policy initiatives relating to poverty and health;

• Explore mechanisms for effective, meaningful and sustainable communityparticipation in decision-making relating to health issues;

• Build the capacity of community health interests to draw out practice andpolicy lessons.

Traveller Health - A National Strategy. Under the National Strategy 2002-2006 itis proposed that “positive steps will be taken to encourage the active partnershipand participation of Travellers and their representative organisations indetermining health priorities for their community and in the decision-making thataccompanies the allocation of resources” (Chapter 3). “Funding will be allocatedto Traveller Health Units to be used to resource Traveller groups to participateeffectively in the units. For example the funding may be used to employ aCommunity Worker, engage in capacity building, health training or primary healthcare training and provide transport and childcare allowances” (Chapter 6).

Department of Health Pilot Programme in support of Health BoardCommunity Development and Health Initiatives. In 2001 funding was allocatedfor Community Development initiatives to be undertaken over the three yearperiod 2001-2003 by each of the Health Boards in their areas. Health Boards wereinvited to submit their proposals to the Health Promotion Unit of the Departmentand monies were allocated accordingly. A variety of projects and initiatives havebeen supported and include: Initiative focusing on Asylum Seekers (SouthernHealth Board); Community Health Action Zones (Midland Health Board);Appointment of a Health Promotion Officer to engage in health promotioninitiatives with the residents of Fatima Mansions (South Western Area HealthBoard); Primary Research into the needs of particular population groups (NorthernArea Health Board).

Each Health Board is required to undertake an evaluation of the initiative. Aninterim report on the Projects will be produced and made available by theDepartment of Health in November 2003.

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Role of Community Work in advancing thehealth and well-being of marginalised andexcluded communitiesThe key objectives are:

1. To advance and influence social and economic policy and programmedevelopment that both promote equality and address the inequalitiesthat currently exist. There are commitments to promote equality and also acommitment to put health at the core of development. However to make thesecommitments real a range of strategies is required to promote health and well-being including:

"equality mainstreaming i.e. incorporating equality considerations into allpolicies, programmes, practices and decision-making, so that an analysisis made of the effects of the policy, the programme, the practice or thedecision on those experiencing inequality. The purpose of themainstreaming is to ensure (a) that appropriate action is taken to redressthe inequalities that exist and (b) to ensure that the policy, programme,resource allocation promotes greater equality for marginalised andexcluded groups and builds a more equal and healthy society.

"the adoption of a human rights framework in the National HealthStrategy and a guarantee to every person in its territory withoutdiscrimination, the right to the enjoyment of the highest standard ofphysical and mental health. Ireland is legally obliged under internationallaw to honour this right. It is the right provided for in Article 12 of theInternational Covenant on Economic, Social and Cultural Rights, whichIreland ratified on 8 December 1989.

"integrated intersectoral responses to tackle inequality, to promote amore healthy and equal society, locally, regionally and nationally. Thisposes a challenge to those who work within the public service in systemsthat are highly centralised and historically have operated incompartmentalised and hierarchical ways.

"health proofing and the undertaking of health impact assessmentsof policy, social, economic and environmental projects and programmes,and resource allocations. It implies the adoption of responsibility by theDepartment of Health and Children, health authorities, the healthpromotion unit and health promotion departments and their officialsnationally, regionally and locally to actively promote the health proofing ofall policies, resource allocations and programmes beyond the healthsector and particularly in sectors dealing with employment, incomemaintenance and social welfare, education, housing/accommodation,transport;

"placing a statutory duty on all public and private bodies to equalityproof and health proof all policies, resource allocations, projects,structures and procedures established in the carrying out of theirfunctions.

2. To ensure that health policy, resource allocation, Primary Care andpersonal services delivery are equality proofed as a priority, to ensurethat they promote equality and redress the health inequalities that currentlyexist. Medical care shall be targeted appropriately on the most marginalisedand vulnerable communities.Equality proofing will require:

"an assessment of the impact of the health plan, investment decision,programme or project on groups experiencing inequality

" resourcing the participation of those groups affected by inequality andtheir organisations so that they can participate effectively in the process

" focusing attention on equality outcomes.Positive action and specifically targeted policies, programmes and resourceallocations will be an essential part of the equality proofing process. ,*


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3. To ensure the active participation and involvement of marginalisedgroups and their organisations in the decision-making in relation toPrimary Health Care, at national and local levels:

"in the identification of needs, in the design and development of PrimaryCare Initiatives in the decision-making about resource allocation and howservices are delivered.

"in the evaluation of health service delivery.This participation of community groups must be acknowledged as part of thenecessary democratisation of the health system and to ensure that the voiceof marginalised groups is clearly heard at all levels in the decision makingstructures and processes.

These objectives need to be advanced and addressed simultaneously. A statutoryduty to promote equality could go some way towards addressing healthinequalities.

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What is the Role of Community Work at local level?

1. By adopting a social model of health, which acknowledges that health is astate of complete physical, mental and social well-being and not merely theabsence of disease or infirmity and working from the perspective that theenjoyment of the highest standard of health is one of the fundamental rights ofevery human being without distinction of socio-economic status, gender, age,national origin, ethnicity, race, religion.

2. By building the organisation of marginalised groups and communities,both geographically based communities and communities of interest, andenabling them to identify needs and priorities for action, and supporting themin their acquisition of skills, knowledge and confidence to engage in collectiveaction to influence and impact on decision-making and policy development atlocal and national level.

3. By enabling local communities, local community platforms and equalitynetworks to develop an understanding and analysis of how inequality isgenerated and sustained in Irish society and how it impacts on health and well-being particularly of the most marginalised communities.

4. By enabling local communities to develop their health agenda and actionplan so that they can influence development in relation to:

"Health and well-being i.e. a complete state of physical, mental and socialwell-being and not merely the absence of disease or infirmity. This implies

#Acknowledging the human right to such a state of well-being.#Developing a vision for a more equal and healthy society and a vision

and sense of what that would mean at local level e.g. in 5 years withina 10 year timeframe.

#Identifying and defining needs that require to be addressed.#Defining and agreeing priorities for action.#Exploring and considering the ways in which the community’s priorities

for action could be put on the agendas of the relevant agencies andpartnership arrangements at local level and defining where thecommunity group could influence policy development. e.g. the LocalDevelopment Partnership, the County Development Board (CDB),Social Inclusion Measures Groups (SIMs) and the Strategic PolicyCommittees (SPCs) of the CDBs.

#Defining and agreeing a programme of action and indicators that couldclearly indicate if progress is being made in achieving the immediateobjectives within a 6 month and a 1 year period.

#Agreeing a process for reviewing progress in the light of thecommunities action plan and objectives.

"Primary Health Care delivery. This will involve:#exploring and identifying the needs of the most marginalised and

excluded groups in relation to health and personal service provision atthe first point of contact, e.g. GP services, dental services, pharmacy,public health nursing services, physiotherapy, occupational therapy,mental health services, home help services, social work services;

#engaging in an impact assessment of current health service provision;#exploring and identifying what the marginalised communities would

consider appropriate responses, processes and procedures toaddress their needs and to deliver the highest standard of health care;

#identifying and outlining the communities priorities and agenda foraction so that it can be presented through the marginalised groupsvoice at the planning table.

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5 By attaining the right to participate in the decision-making process inrelation to the development and delivery of Primary Health Care at local level,articulating the experience of excluded and marginalised communities andnegotiating and advancing their priorities and agenda for action. This means:

"Being resourced to identify needs, to develop the communities ownhealth agenda, to develop knowledge, skills and capacity to effectivelyengage in any partnership process.

"Asserting the independence and autonomy of the community sector andthe right of the marginalised communities to nominate their ownrepresentatives and those who will speak on their behalf.

6 By ensuring that the Primary Health Care planning and delivery isequality proofed at local level. This implies equality proofing policies,programmes, resource allocations and implementation plans, operationalprocedures and decision-making structures. It also implies targeting positiveaction on the most marginalised and excluded communities to redressinequalities that currently exist.

7 By bringing the communities’ health agenda into the social andeconomic development intersectoral partnership arrangements e.g. theLocal Development Partnership, RAPID, the Social Inclusion Measures (SIMs)Group of the City or County Development Board (CDB) and ensuring that allpolicies, programmes, resource allocations are health proofed and equalityproofed.

8 By developing links with the national Community Platform, Public HealthAlliance and the Health Linkage Network to build alliances with groups andorganisations working to promote equality and address health inequalities; andto develop understanding of collective strategies to advance social andeconomic development that ensures greater equality outcomes and healthgain for marginalised communities.

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CASE STUDIESCASE STUDIES

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CASE STUDIES

IntroductionFour detailed case studies are offered in this section to facilitate exchange ofexperience and ideas, and approaches and methodologies to address healthinequalities. They are also presented to stimulate reflection and discussion on theobjectives of our own work, and on the perspective that we have/are adopting inour work practices.

The case studies that have been chosen for inclusion in the Strategy Guide reflectdifferent contexts and scenarios and reflect different agendas being pursued toaddress health inequalities by four different projects. But what the Projects havein common is their commitment to address inequality and social exclusion, therights based approach and the use of Community Work principles in theirinterventions for social change.

The South Tyrone Empowerment Project is a partnership of CommunityDevelopment groups that was originally established “To address the absence of abasic framework in which the most marginalised, vulnerable and therefore mostexcluded groups in the rural region of South Tyrone could develop confidence,social and organisational skills; and access the resources necessary to affordmore equitable participation in the formulation, development, decision-making anddelivery of projects”. STEP “doesn’t do health”, nor is it involved in the delivery ofhealth services, but its focus on Community Work takes it into the health arenaand it supports local community organisations to develop their health agenda.STEP’s health agenda takes it into many partnership arrangements to advocate,pursue and ensure equality outcomes for the most marginalised target groups andcommunities.

Women’s Health Action, a project of Cairde. Cairde is a CommunityDevelopment project, located in Dublin, and working with ethnic minorities toenable them to address issues which affect their health. The particular piece ofwork chosen as a case study focuses on how particularly vulnerable andmarginalised women have been facilitated to engage in a collective process ofpersonal development, of identifying needs, to develop skills as a group toundertake a research piece, analyse their findings, develop their leadership skills,develop an agenda and action plan and begin to impact on policy at local andnational level.

A Voice for Older People is a pilot Community Development Project in Donegal,supported by the North Western Health Board. It was established to enhance thecapacity of older people to identify and articulate their quality of life needs, todevelop a collective voice in relation to these issues and to play a lead role increating the change necessary in order to achieve equity, social justice andimproved quality of life. Older people experience social, economic and culturalexclusion in the area which has an impact on their health. This project isspecifically designed to engage older people in an exploration of the nature ofsocial exclusion of older people, ageism, changing social structures and economicand development policies that impact on their lives, and to engage them inarticulating and implementing a collective vision for the future, with clear agendasand local action plans for change.

The Traveller Primary Health Care Project is now in its tenth year. It is a projectof Pavee Point, an NGO committed to the attainment of human rights forTravellers. The Project developed a model of service delivery to one of the mostmarginalised and excluded groups in Irish society, a model which has beenreplicated and is promoted in Traveller Health - A National Strategy. The casestudy explores the history of the project, the principles and approach which haveunderpinned the Project in its development, consolidation and expansion. Itoutlines a number of the targeted initiatives that were designed to address needsidentified, and the outcomes of the project including its impact on policydevelopment and the challenges which currently face the project.

The contribution of the Projects, their co-ordinators and staff to the presentation ofthe case studies is warmly acknowledged. The case studies draw on documents,reports and evaluations that have been written and prepared by and for thedifferent Projects as well as conversations and interviews with representatives ofthe Projects.

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The South Tyrone Empowerment ProjectA Community Development Project with a HealthAgenda using Community Work approaches toaddress health inequalities

What is STEP?The South Tyrone Empowerment Project (STEP) is based in grassrootscommunities and at the same time is actively engaged in attempting to inform andinfluence policy development and practice at various levels and in variouspartnership arrangements at regional level.

It is located in the southern part of the western rural region of Northern Ireland,running along the border with the Republic of Ireland. It is a scattered ruralcommunity pop 45,500 approx. (1991). The area has one district town (pop 9,500)and several scattered villages. STEP defines the features of the area asperipheral, fragmented, with poor infrastructure, uneven socio-economicdevelopment, high population growth, high level of out-migration, highunemployment, high dependency levels, a low level of sustained participatorysocio-economic development, low level of self employment. Very high proportionof community segregation (percentage of enumeration districts with 80% + fromone section of traditional community) and highest number outside of Belfast/Derrycity area of persons per thousand killed/injured/imprisoned in the past thirty years.

STEP was established in 1997 to address the absence of a basic framework inwhich the most marginalised, vulnerable and therefore most excluded personsand groups in the community can:

1. Develop confidence, social and organisational skills;

2. Access the resources necessary to afford more equitable participation in theformulation, development, decision-making and delivery of projects.

Why was STEP created?The stark reality in 1997 was that those in the local community for whose benefitthe European Structural Support Programme for Peace and Reconciliation hadbeen devised, had little or no capacity, process or infrastructure through which torelate, or effectively benefit from the programme.

The problems identified in 1997 were:

1. the poor economic infrastructure, the absence of community infrastructure, thelack of access to information, training and expertise which would enablegrassroots and marginalised communities to participate in socio-economicdevelopment

2. mainstream labour market was unable to keep pace with the growth in thelabour supply

3. the background of sectarianism and community mistrust

An innovative integration approach was adopted by a number of diversecommunity based groups sharing a participatory ethos. They were determined toaddress the problems they had identified. These stronger local community groupsin the district formed a partnership (STEP). These diverse community groupsagreed a very clearly defined agenda. STEP was created to provide a supportiveconduit to the most marginalised and excluded groups:

• to assist such communities to access, interpret, evaluate and utiliseinformation in identifying their own needs;

• to assist groups and individuals to develop organisational skills and accessopportunities and training to address identified needs;

• to develop local capacity to act independently of the district-wide communitypartnership, and

• to develop a network and infrastructure which would simplify and sustain theinteraction between community groups and individuals across the district. %%


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Working Collectively to Combat Exclusion

The eight partners (diverse community groups) pooled their resources, andcreated a team of eight workers dedicated to creating an empowermentprogramme. The intensive nature of the project and the location of the workers inthe marginalised communities enabled those most excluded to be activelyinvolved at all points of development. The development was co-ordinated by anoverall programme co-ordinator. Each worker had three elements to their role theyconcentrated on:

• a specific aspect of ‘exclusion’ e.g. disability, women

• a particular geographic location, and

• developing a specific area of vocational competence.

Each of the partners in the project

• nominated a person to the partnership Board which determined policy and wasresponsible for the STEP project

• hosted a STEP worker, providing physical space and resource support

• undertook internal monitoring and evaluation responsibilities

• co-operated in the delivery of the project.

The Board met every 4-6 weeks. A sub-committee (management committee) metbetween meetings and liased with the co-ordinator. The co-ordinator and eightworkers met weekly ensuring an organisational and strategic approach to theirwork.

Each worker’s tasks had three elements:

• district-wide theme based team work, led by the Community Workerspecialising in the field e.g. Disability, Youth, Women

• local grassroots Community Work and capacity building and training work inthe geographic area in which they were based with the assistance of their‘host’

• accessing information from existing sources within and beyond the district tomeet the needs identified

The project has achieved very significant success since its inception in 1997.STEP’s commitment to the empowerment of the grassroots communities and toinforming and influencing policy development, its commitment to be accountablefor the investments by the project, means that emphasis is placed on monitoringand evaluating its work and its impact, and sharing the lessons from its work.Much of their work is documented.

“We don’t do health, but Community Development takes us into health”

STEP first got into health in 1998 when the London-based ‘Fit for the Future’consultation was being undertaken. It was prior to the establishment of theNorthern Ireland Assembly and Executive. Consultations were taking place acrossNorthern Ireland. However, STEP’s target groups, like the other communities thatlived in areas of proposed hospital closures, were not invited to a consultation.

STEP’s target groups had a lot to say about their health needs, about healthservices and about the proposed closure of the hospital. So STEP organised, withthe help of the Community Development and Health Network, a consultation intheir area. They put particular effort into consulting with young people and peoplewith disabilities. Anxious to take forward the issues that were identified in theconsultation, they sought advice from the Belfast Economic Forum about anyhealth initiatives that they could tie into.

STEP discovered that although Health Action Zones (HAZ) were being widelypromoted and developed in England, no application for a HAZ was made by anyof the Health Boards in Northern Ireland.

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Key elements in theframework that facilitateddevelopment within themost marginalisedcommunities

�community partnership of -strong groups established tobuild and support newcommunity groups(geographic communitiesand communities ofinterest)

�pooling of resources andexpertise to benefit theweaker more marginalisedareas

�intense nature of theproject

�clear elements in the role ofeach staff member

�weekly meetings toexchange information andexperience and to ensurestrategic approach in thework

�an active Board

STEP decided to go for a grassroots needs assessment with a view to finding outwhat could be done differently and to influence health policy and practicedevelopments. For the purpose of the Project, STEP formed a partnership with theSouthern Health and Social Services Board (SHSSB). Nexus Research werecontracted to do the needs analysis. The report was published and the SHSSBused elements of the analysis and findings of the report to put in its bid for a HAZ.Community Groups were not eligible to apply for a HAZ.

The SHSSB was successful in its application and STEP then defined itsorganisational strategy towards HAZ. STEP is represented on the StrategicAlliance Group, the intersectoral group that oversees the HAZ Programme withstate agencies that include the Housing Executive, Education, Environment. TheSTEP Co-ordinator represents the organisation at the second tier (HAZ SupportGroup) and currently chairs this advisory group that co-ordinates the three priorityprogrammes of the HAZ: Rurality; Housing; and Youth. Staff members representSTEP on each of these three programme groups and the organisation is activelyinvolved in developing seven of the nine initiatives that are being developed underthe HAZ umbrella. An evaluation and impact assessment is currently beingundertaken on the HAZ by the Institute of Public Health.

Helping Communities Develop their Health AgendaSTEP as part of its capacity building and support to grassroots communities thenfacilitated five communities to design and develop proposals for Healthy LivingCentres funded by the New Opportunities Fund. Again the approach to thedevelopment of the centres and the funding proposal was a strategic one andsought to integrate. The strategy was to support the development of eachhealthy living centre in a way that would maximise the efficient use ofresources and develop each centre in a way that it would compliment,support and reinforce the effectiveness of the work of the other four centres.It collectivised community effort and sought to collectivise communitybenefit. The needs in five projects differed: in one the challenge was to meet theneeds of a predominantly older population; in another the challenge was to findways to address male suicide. Each project was designed to address its keyneeds, and, also to provide its expertise and support at a regional level to each ofthe other four projects, to pool their staff and resources of a specialist nature forthe benefit of all.

Developing Local Expertise in Community Work Approachesto HealthSTEP recognised that many of the people who are key to the developmentprocess in local communities are not necessarily those with formalqualifications. Enhancing the skills, knowledge and expertise of grassrootscommunity leaders is a key element in STEP’s work to address healthinequalities. Initiatives undertaken include:

• The development of partnership arrangements with the Health Board andothers to support grassroots community leaders with the information and skillsthey need to work within communities on issues such as child protection, druguse, and to use effective Community Work approaches to address healthinequalities.

• Training for Trainers in Community Development and Health - a course inHealth Awareness and Good Development Practice for local communityactivists and appropriate STEP staff.

• A pilot study to improve participation in training especially in relation toaddressing women’s health issues. This programme had a number of verysuccessful outcomes, including the development, extension and delivery of theprogramme in a number of new areas in South Tyrone; the adaptation of theCommunity Development and Health Network’s Training Course to take onboard the lessons and findings of the pilot; the successful negotiation by STEPfor accreditation of the course by the NW Institute of Further and HigherEducation, many of the trained local community activists are now contractedas tutors by the NW Institute of Further & Higher Education to deliver thecourse.

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Addressing Inequality in the Mainstreaming ProcessCommunity Work approaches to health and health inequalities were piloted,programmes and courses were designed, developed and implemented. Manywere deemed successful and worthwhile and decisions were made to mainstreamthe work. However, when the Community Development and health work wasmainstreamed and the paid jobs were officially created, the community experts,whose expertise and unique experience was acknowledged as being at the coreof the successful delivery of such programmes were left outside themainstreaming process.

At the moment SHSSB Community Development related positions are advertisedas requiring a degree or equivalent (Community Work experience is not required).And so those with no expertise in Community Work, or those who have none ofthe Community Development experience which was deemed so crucial to thesuccess of the pilot programme in the first place, are employed to advance thework developed by local activists often working in a voluntary or unpaid capacity.For STEP it is a clear equality issue.

STEP is engaged in discussions in the Community Development Strategy Panelof the SHSSB to address this inequality. STEP feels very strongly that

• When Community Work approaches to health and health inequalities aredeemed successful and worthwhile and a decision is made to mainstream thework, then the person(s), the way of doing the work, and the process of doingthe work should also be mainstreamed.

• Community Health workers once employed should be facilitated to acquireprofessional qualifications as part of their staff development.

Engaging in Partnerships to Influence Policy DevelopmentSTEP’s core belief is in its independent strategy. However its health agenda andits commitment to influencing policy and practice engages it in many partnershiparrangements with state agencies. The nature and level of involvement variesfrom one initiative to another. In some cases, a member of STEP staff is directlyinvolved in a partnership arrangement or working group with other sectoralinterests. In other cases, STEP is supporting the involvement and self-representation of ‘grassroots’ community activists in partnership arrangements.

As a result of the strategic and Community Development work of the past numberof years, STEP now engages with over 150 community groups. There are nowCommunity Forums across the district that have grown organically as a result ofthe STEP empowerment strategy.

STEP staff meet fortnightly as a team, this facilitates an organisational andstrategic approach to their involvement in influencing policy and to their grassrootswork in relation to Community Development and health.

STEP also engages with a number of different cross-sectoral and NGO networksto access and exchange information, for support, to contribute as appropriate, toraise awareness of concerns and issues expressed at grassroots level. Some ofthe networks work strategically, others do not.

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Supporting the Self-Organisation of Migrant WorkersCurrently featuring on STEP’s health agenda is the health and well-being ofmigrant workers, the lack of appropriate responses to their health needs and theneed to inform and influence policy and practice in relation to Primary Care andeffective and appropriate health service provision.

Many migrant workers have arrived into the area in the past year brought intoNorthern Ireland by local employment agencies to work in a particular section ofthe food industry i.e. in the chicken factories and abattoirs in the general area. Theagent is the employer of the migrant worker, the location of his /her employmentcan vary and s/he can be moved without notice from one place of employment toanother. Accommodation is provided by the agent and provision is tied into theterms and conditions of employment. The contracting process, and the terms andconditions of migration and employment have a negative impact on the workershealth and well-being. The migrant workers are in the main EU citizens, beingPortuguese and Portuguese-speaking migrant workers from former Portuguesecolonies.

STEP has established a Migrants Rights Centre in Dungannon and usesCommunity Work approaches in its advocacy work, provision of information onrights and entitlements, support and capacity building initiatives to build the self-organisation of the migrant workers. The Community Work with the migrantworkers, supports them to identify and analyse their needs, explore and identifyappropriate responses to meeting their identified needs, set their own agenda andan action plan to be advanced, including linking into wider networks that promoteequality and social inclusion.

Informing and influencing policy and practice in relation to addressing the healthneeds of the migrant workers is currently undertaken by STEP staff. The strategyemployed by STEP ensures that an opening is created by the co-ordinator to putthe health of migrant workers on the agenda of the health sector. The co-ordinatorpresents an analysis to inform policy makers of the issues, STEP staff thenparticipate in working groups or follow up meetings to ensure that the needs areappropriately and adequately addressed by way of new policy and practice orchanges to current policy and practice. The workers hold these negotiatingpositions until there is sufficient capacity building done to enable the marginalisedgroup to represent its own interests.

The process to date has involved meetings with the health sector and the healthprofessionals and health service providers to:

• Inform them of the experiences of migrant workers and their difficulties inengaging with the health system, in registering with GPs, dentists, inaccessing services, in finding out how the Northern Irish health services work.

• Inform and sensitise them to the impact of the employment contract and theworking and living conditions on the health and well-being of migrant workers.Many GPs complained that migrant workers are only willing to attend inemergencies and do not keep follow up appointments. Health professionalsare unaware of the vulnerability of migrant workers, of their fear of losing a job,of being considered ‘not up to the job’ should they appear ‘sickly’ or ask fortime off to go to a doctor.

• Make them more aware and conscious of the need to take on board the socialmodel of health and of their obligations as health professionals to giveleadership in promoting the health proofing of employment practices.

• Explore ways of appropriately accommodating the needs of migrant workersin the Primary Care area, including the many different practical ways in whichservices could be offered bi-lingualy, particularly regarding the provision ofinformation, when and where health assessments should be undertaken.These meetings have also provided the opportunity to define the flexiblearrangements, procedures and practices that would characterise a moreresponsive health system and meet the needs of minority ethnic groups in anincreasingly multi-ethnic and multicultural society.

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Community Development is very good for your health... STEP would like to prove itThe differences in the health and well-being of individuals when they are first metby the project workers and then after a while when they are engaged with othersin an empowerment process is very obvious and apparent to those who work inSTEP. It is also very obvious to the individuals and groups who participate inCommunity Development programmes and projects. “People want to get out ofbed in the morning, they feel valued as human beings, they develop confidence,speak for the first time, walk differently, they acquire new skills, knowledge andcompetencies, develop social networks, they engage wholeheartedly incontributing to change in their own communities”.

A question regularly posed in STEP is: Does our organisation have a biggerimpact on people’s health through (a) our independent CommunityDevelopment work, or (b) through the energy we apply and the biginvestment of time and human resources that is required to work with theSHSSB in its various and vast range of committees, meetings andpartnership arrangements? According to STEP, evidence would suggest that itsindependent Community Development work is having a much bigger impact onpeople’s health and well-being than the health promotion campaigns and many ofthe healthy communities initiatives.

STEP would like to measure the health impact of its work over a period of time andhas applied for funding to monitor the health impact of the communitydevelopment work and to undertake a health impact assessment over a five yearperiod.

Is Community Development good for your health? STEP feels it would be veryeasy to measure the impact of its work on people’s health and well-being. STEPalready gathers data from participants of STEP programmes, it is a requirement offunding. “We are in a position to invite participants to answer a few morequestions, if they wish, in relation to their health status e.g. do they smoke, whatwould they consider to be their current stress level on a scale of 1-10? Do they selfmedicate with drugs? How often do they see the GP? If people fitted certainprofiles e.g. blood pressure, they might be willing to participate in the monitoringof that category”.

STEP would then monitor changes in participants health and well-being.Participants themselves would also be monitoring, evaluating and acknowledgingthese changes.

The application under the Investing in Health Programme, for the cost ofadministering the monitoring system, is currently being considered. “We havealways wanted to know how much we save the health service in terms of visits tothe doctor, in medication, in treating illness. Research shows that people with thepoorest health have the lowest self esteem, the lowest levels of literacy andeducational attainment and are the least active in their own lives. They are alsothe poorest, it’s a vicious circle”.

STEP has long acknowledged the links between literacy and health inequalities.All STEP Community Workers have trained as literacy workers, they have anappreciation of literacy and therefore do literacy training.

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Key lessons from the Community Development work to dateand the work of STEP in advancing its health agenda

1.Community Groups should not rush into health projects.This is the first lesson that STEP draws from its experience. The Projectacknowledges that there has been a shift in the community role and a push tomove community organisations into service delivery on behalf of the state - andsometimes cut-price service delivery. “There is a need to get back toCommunity Work and to be very clear about the focus of Community Workand Community Development”. Community Work is an intervention for socialchange. It is about empowering the most marginalised, vulnerable and excludedgroups and communities so that they can have a say in decisions that impact ontheir lives. It’s about community organisations informing and influencing policydevelopment and promoting social change. That is the business of CommunityWork. “In an odd way our job now is to get the community to mind its ownbusiness and get back to doing its own job properly”.

2.Community groups should not be encouraged to sit on partnership boardsCommunity groups should not be encouraged to sit on partnership boards withan array of health professionals when they have little confidence and have nostrategy or agenda of their own and when they have little understanding ofhealth strategies. State agencies or the health professionals, may claim to havethe community on board, and their plans and proposals can be perceived to belegitimised by the presence and co-option of individuals from the community, butcommunity groups can be easily abused and patronised in these circumstances.When fledgling community groups wonder if they should engage in a partnershipSTEP believes that there is a need to be honest with groups and say, “as thingscurrently sit, ‘No’ is a good answer”. STEP acknowledges that the lack of healthservice provision is a huge problem for community groups and for marginalisedcommunities. “But we need to say to the community group ‘It’s neither yourresponsibility or within your ability to solve the problem. Consider instead whatyou need to say to others to get the problem sorted, to get those withresponsibility to move and focus on the problem?’”

3.Need to be strategicThe role of organisations like STEP is to teach people to be strategic in relationto working for a healthy and more equal society, to work out ‘What they want;Why they want it? How they intend to get it? What might be the difficulties andchallenges along the way? How they could meet these challenges andovercome the difficulties as they arise?’ When a community group has workedout what it wants and why it wants it and has worked out all the angles, then thecommunity group is confident, is prepared and has a greater chance of beingsuccessful in progressing its objectives.

4.Need to understand & appreciate the agenda of funding bodiesIt is most important that community groups understand and fully appreciate theagenda of the funding bodies and the state agencies that offer grants to promotecommunity health. “Community groups need to always ask ‘Do we want thatagenda and money? Is there room to negotiate or re-negotiate additional oralternative objectives? Can we really negotiate different terms of reference forthe worker, or for the project?’ Too often groups identify their real needs and thendistort their needs to get the money. This gives rise to all sorts of tensions andproblems”. The community group should have its own core objectives developedbefore it engages.

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5.Need for real consultationA presentation of the opinions and views of a Community Worker does notrepresent a consultation with local communities. Often when CommunityWorkers meet with the state, they are asked for their opinion. CommunityWorkers should not allow themselves to be used as an alternative to aconsultation with marginalised communities for their views, most especiallywhen the state is unwilling to resource the participation of marginalisedcommunities in the development process. Community Workers can offer tofacilitate a survey of the community views, through focus groups, meetings, andshould enquire about and request the resources to do so. The state shouldacknowledge its responsibility to consult appropriately.

6.Achieving ChangeMaking change is not dependent on individuals. A critical mass is necessaryto make change in any partnership arrangement. The right individual in theright place at the right time shortens the process. Real change can only besustained through hard work and when there are people engaged beyond thepartnership structure.

7.The State needs to contract Community Work / Community DevelopmentexpertiseThe Community Work and Community Development expertise within thecommunity sector should be contracted by the state to provide staff developmentwithin its departments and agencies. Community groups are often trying toexplain Community Development at meetings. There is a responsibility on thestate to develop its staff’s knowledge and understanding of CommunityDevelopment. There is a role for the community sector in this staff developmentprocess. It needs to be formally invited and engaged to deliver training.

For Further Information ContactBernadette McAliskeyCo-ordinatorSouth Tyrone Empowerment ProjectUnit T7, Dungannon Business ParkDungannonCo Tyrone BT 71 6JTPhone (028) 87729002 / Direct from the Republic of Ireland: 048 87729002

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KKEY AACTIONS

We don�t do health" community work took us into health�When the project�s target groups were excluded from a health

consultation" they organised their own�With a health agenda they then pushed for policy development and the

creation of a Health Action Zone

The Project:�supported local grassroots communities to develop proposals for Healthy

Living Centres�created training and development opportunities for local people to

develop knowledge" skills and competencies so that they could giveleadership in the community work process to address health issues andhealth inequalities

�put women�s health issues on agendas�got accreditation so that local trainers can be contracted as tutors on

outreach college courses�engages in a range of partnership arrangements with the state and in

regional health network of statutory and community organisations" tokeep the health and well!being of marginalised groups on their agendas;engagement in equality network with community" equality and humanrights groups

�advocates on behalf of migrant workers and their health needs whilesimultaneously supporting the self organisation of migrant workers sothat they can represent themselves#

Elements of Good Practice� Strategically focused� Two pronged approach: it is based in grassroots communities and at the

same time is actively engaged in attempting to inform and influencepolicy at a range of different levels and in different arrangements#

� Sees opportunities" creates opportunities" seizes opportunities to putissues on the agenda of stage agencies and development bodies

� Clear in its community work and equality focus� Solidarity is its starting point� Works with grassroots communities and targets and empowers the most

marginalised communities and groups� Collectivises community resources" effort and expertise to ensure

maximum benefit� Develops local leadership" local skills and expertise ! builds social capital

and sustainable communities� Builds and supports the self organisation of particularly excluded and

marginalised groups and advocates at the policy table on their behalfuntil such groups can represent themselves#

� Works from the perspective of the social model of health" but alsochallenges structural inequalities in the health service and in healthservice delivery#

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A Voice for Older PeopleA Community Work approach to working with OlderPeopleIntroductionThe Project was established in January 2002 by the North Western Health Boardfollowing the successful submission of a proposal by the Community Developmentworker to the Department of Health and Children’s New Communities Projects. AVoice for Older People is one of eight pilot projects focused on innovation inCommunity Development and Health and financed by the Department of Healthand Children for a three year period. The project is being developed and co-ordinated by the community development worker. It has a European dimensionwith partners in France and Estonia. It is expected that the Project will contributea model of good practice that will be transferable, and that A Voice for OlderPeople will become a strong, independent autonomous network with strategiclinks, including a strategic link to the Choice Programme33 of the North WesternHealth Board.

The Project VisionDonegal is a large county, vast in territory, but poor in terms of infrastructure andservices to link local communities. Many people are impoverished in both thepopulated areas and towns. Those who are not well-off are not able to readilyaccess services. The infrastructure and the provision of services is particularlypoor in very isolated areas where the population is more scattered. Older peopleespecially experience social, economic and cultural exclusion and marginalisationwhich has a major impact on their health.

A Voice for Older People aims to enhance the capacity of older people inDonegal to identify and articulate quality of life needs, to develop acollective voice in relation to these issues and to play a lead role in creatingthe change necessary in order to achieve equity, social justice and animproved quality of life.

The Project is placed in the social, cultural and economic reality of older peopleslives in Donegal. It explores the present situation by examining the history andnature of social exclusion of older people, the present forces - ageism, changingsocial structure, economic and social policies as well as articulating andimplementing a collective vision with actions for the future.

Adopting Community Work principles and a social model ofhealthAcknowledging the Diversity amongst Older PeopleThe Project takes as its premise the heterogeneity of older people and recognisesthat cohorts or groups of older people who share the same birth year do notnecessarily share the same experience of ageing. It also considers that ageingdoes not occur merely as a consequence of chronology but is shaped by societyand social structures and that inequalities of gender, class and ethnicity existingthroughout the life cycle do not dissipate in later life but continue to decree accessto resources such as income, health and services.

Ageing therefore cannot be considered in isolation as a purely biological processbut must also be viewed as an experience, which is socially constructed andtherefore needs a holistic and rights based approach to meeting the quality of lifeand health needs of older people.

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%% The Choice Programme is a Strategy of the North Western Health Board with a full!time Co!ordinator# It has a philosophy of care" giving older people a choice abouttheir care and decisions about their care needs and how the Health Board couldrespond to their needs#

Capacity building for social change

The Project builds from the bottom up - taking as its starting point the diverseneeds of older people living in different settings: at home, in the community, inprivate nursing homes, in hospital, etc. It is older people themselves whocollectively decide on relevant issues for action. An essential feature thereforeis the emphasis on participation, issue exploration, discussion, analysis andsubsequent group development. It encompasses a creative approach to socialanalysis using drama, creative writing stories, video, role playing. It is from thisanalysis that ownership, collective thinking and active citizenship is fostered andthat the target group - older people - become investors in their own developmentbecoming part of the process of change. Older people are actively involved inthe participatory action planning and either directly and/or indirectly inimplementation and evaluation. Other key elements in the empowerment andsocial change process are general and specific skill development and the creationof structures and networks that maximise community involvement to ensuregreater equality outcomes. Within and throughout this approach and way ofworking, the threads of active community participation, partnership, equityand social justice are woven.

What makes this project different is that it was designed and is being developedto be older people owned and older people led. A Voice for Older People.

Being strategic - a two-pronged approach to affecting social change

The Project acknowledges that to be successful in achieving its objectives, it willrequire the development of a service sector that is open and willing to listen andwilling to act on identified issues. Only then will there be more effective health careand health related policies. The Project therefore adopts a two-pronged approachto effecting social change. The strategy for engaging with the state entails acapacity building programme with the Health Board sector and capacity buildingwith the other statutory and non-statutory agencies and bodies that provideservices to older people. Statutory and non-statutory service providers are alsoencouraged to engage in the intersectoral partnerships and collaborationsdeveloped by the project to achieve its aim.

The Project has four key objectives:

• Development of a representative and recognised forum of / for older people inDonegal (with clearly identified roles)

• Development of five local working groups based in identified geographicalareas (with clearly identified roles)

• Development of a community based education and development strategy andleadership training strategy for older people. This is key to the sustainability ofthe Project and to ensure that A Voice of and for Older People is older peopleled and owned

• Development of a project evaluation framework, which can be used as aresearch action tool using the principles of Community Development

The following four stages have been identified as core to a CommunityDevelopment approach and are incorporated into each objective:

• Pre-Development• Development• Community Action and• Evaluation

It is planned that this forum will be the collective voice of / for older people in thecounty from a local and county level and will become an invaluable two wayresource for linking, networking, gathering, inputting, channelling anddisseminating information on issues that have been collated from local, county,national and European level.

Elected representatives from this forum will link directly at policy making level tovarious bodies i.e. Area Partnerships, Vocational Education Committees, CountyDevelopment Board Community Forum, ‘Choice’ in North Western Health Board etc.

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Stage 1: Pre-Development StageEstablishment of ad-hoc steering group to support the development of theProjectThe Community Worker invited a number of people active on older people’sissues and the commune workers of each of the three local developmentpartnerships in the county to participate in an Ad-hoc steering group to supportthe development of the Project.

Collection of data and the development of a baselineWork began on the collection of data and information, internationally, nationallyand locally, and on the development of a mapping process which would provide abaseline and assessment of where older people live, the different settings in whichthey live; the agencies providing services; the types of services, the location of theservices and an assessment of services that are provided; the gaps in serviceprovision, who is linked in and who is not linked in; how power is defined andwhere power is located; and where leadership lies at local and county level. Thisis an ongoing process which is added to at each consultation and with each pieceof work that is undertaken at local level.

Interesting discoveries were made. While many perceived that there was littleinformation on the situation of older people in the county, there was very clear dataavailable but it had not been previously accessed or collated by communitygroups. The Health Board, Public Health Department has all sorts of populationstatistics, data and information for each District Electoral Division (DED) in itscatchment area, e.g. the population of the DED, broken down by age and gender,numbers of lone parents, mortality and morbidity rates, numbers of medical cardholders, breakdown of types of housing and accommodation etc. The informationis not readily available for a particular housing estate, or a village, or a townland,but if people ask for information for specific DEDs (they will need to know therelevant DED or the DEDs for which they require the information) - all sorts ofvaluable information is available. Having this information allows groups to seeexactly what the population density is in a particular DED, how close thatpopulation is to hospitals and other services including transport routes etc. It canbe very helpful in developing an analysis of inequalities and inequity in serviceprovision or in access to services. and in campaigning and lobbying for change.The county council also has valuable information with deprivation index. Acomprehensive County Profile has been produced by the CDB and a County Atlasis also now available which gives comprehensive information in a range of keyareas. The atlas is available for reference in the library, educational institutions,and with community networks in the county.

The mapping exercise facilitated a process engagement with service providersand a process of networking with voluntary service providers and groups workingwith older people and reinforced an understanding of the need to develop strategiclinkages and affiliations with appropriate agencies and groups. It also reinforcedthe view that to promote a social model of health, the project would need topromote and develop an understanding of the links between health and well-being,social inclusion and development and promote collaborations, with those ineducation, especially those in the VEC, second chance education, the artsworkers, the library service, the county council, the transport sector, social andfamily affairs, the health board, the Gardaí and the voluntary organisationsworking with older people - Care of the Aged, Community Alert and the St. Vincentde Paul.

Dynamic and open-ended consultations - a defining feature of the ProjectAn important part of this pre-development stage was the initiation of theconsultation process, which continued into the development stage. Thisconsultation is key to the energy, ownership and success of this project.Exploration and analysis of issues took place at both local and county levels-atlocal level at open meetings and with the emerging working groups as well as withrepresentatives and stakeholders at county level and at national level.$$


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Work of the Pre!Development StageEstablishing an ad!hoc steeringgroup to support thedevelopment of the project;

Commencing the MappingExercise" developing thebaseline data;

Developing strategic linkageswith appropriate agencies

Promoting the social model ofhealth;

Consultation with olderpeople" naming some of thereal issues;

Preparing for the developmentof Local Groups and theCounty Network;

Capacity building for thedevelopment phase#

Local Consultations.Local consultations were organised in a series of locations. They were promotedand advertised with a very clear and simple outline of what the consultation wasto be about. What is it like to grow older in this area? What are the issues? Howcan we move these issues forward? Members of the ad-hoc group identified andtargeted those actively working with older people in the different locations andletters were sent to formally invite them to a half day meeting. The consultationswere advertised on local radio, and posters and notices were posted in the LocalDay Centres, shops, Post Office, and churches inviting people to come along. Tea,coffee, soup and sandwiches were provided.

The consultations were very well attended by older people and by peopleconnected to the Local Development Partnerships, CDPs, service providers,community arts, voluntary and statutory service providers, and many older peoplewho were not connected to any organisation came to the consultation. Manyissues were raised and discussed. After each consultation, people volunteered toform a local working group to help move the project forward. These emerging localworking groups documented and analysed all of the issues that were raised in theconsultations, this contributed to the development of local profiles and themapping exercise and also fed into the county mapping process.

At the same time the ad-hoc county group continued with its analysis of issueswith stakeholders at local and national level and with the emerging local workinggroups.

Designing and Developing the Education and Leadership DevelopmentStrategy: Establishment of a Working GroupA working group of relevant partners including the VEC, the Library, SecondChance Education for Women Initiative, Hollywell Trust, the Arts Officer with olderwomen and men was established with a view to advancing the community-basededucation and leadership development strategy for older people. A Mappingprocess was begun with regard to resources and provision and information wasgathered about other initiatives, nationally and in a European context, that wouldbe of interest to older people.

Outcomes of the pre-development phaseThis process of dynamic and open-ended consultations throughout this stage hasenabled real issues to be identified and real trust to be developed; for examplesensitive issues such as elder abuse, violence, relationships, loneliness as well aseducation and training needs, for stories and voices to be heard about poverty andfear for in many circumstances the first time. The use of guided facilitation, video,creative writing, group discussions, poems, dance greatly enhanced this process.

The process of animation and capacity building and the building of partnershipswas key to this process resulting in the development of one county steering groupand five local working groups. For the first time in the county the Gaeltacht areasaligned themselves strategically with non-Gaeltacht areas.

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Stage 2: Development StageThe second stage of the project is interlinked with the first, however in this phase,at local and county level, a more developmental approach was being adopted toemerging issues from the mapping, the linking and the consultations.

Development of the Local GroupsIn this phase the local groups continued with the mapping exercise, the communityprofiling and audits; continued their consultations and networking; developed theirunderstanding and analysis of the issues and needs being identified; fed into thedevelopment of the county plan for A Voice for Older People. They began theprocess of prioritising the issues and needs identified at local level and that woulddefine the basis of local action plans.

Concurrently ongoing developmental work was undertaken with the local groups.They were facilitated by the project development worker and outside facilitators insessions that focused on personal development, team building, social analysis,the development of appropriate structures to advance and represent the agendabeing developed and representation on the County Network.

A County-wide Steering Group was established which includes older people,members of the voluntary, community and statutory sector, as well asorganisations / individuals working with older people.

The steering group consists of 70% older people and 30% agencies and definesitself as an umbrella group of groups and individuals working with older people forthe development and advancement of issues affecting older people in Donegal.Twelve of the nineteen places on the Steering Group are designated for olderpeople and one place is designated to the organisations of older people. Each ofthe local groups are represented on the County Steering Group.

The group were facilitated to do a SWOT analysis (Strengths, Weaknesses,Opportunities and Threats) to help it define the potential, the weaknesses, thestrengths and the opportunities for advancing older peoples agenda for change,and to help them to develop a good two year strategic plan. As a result of thegroup doing the SWOT analysis, and much discussion, it identified and agreedfour roles for itself. These were to:

1. facilitate the exchange of information, communication and co-ordinationbetween groups in the county.

2. advocate the needs of older people.3. influence decision makers with respect to the needs of older people.4. develop new projects as identified by local groups.

The Project worked with a clear Community Work perspective - as needs wereidentified - skill development was introduced - representation and how to get yourmessage across, negotiation, advocacy, information dissemination etc.Developmental work and training is ongoing - team building, developing arecognised structure with clearly defined roles etc.

Advancing the Education and Leadership Development StrategyThe group discussed the preparation of a Programme of Work that would bespecifically targeted on older people who are not actively engaged in activity atlocal level. This action would require a two pronged approach: the design of eventsthat would attract and not intimidate such older people; and having the support ofothers and projects such as the CDPs who could encourage the older people toattend. ‘Old Age is a Privilege not Given to Many - Enjoy it’ was designed as thefirst event that would focus on enhancing the self-esteem of older people, as acelebration of the individual. It was not designed to focus on issues but it wasexpected that issues would be raised in the process. Twelve two-day workshopswere planned to take place in particular areas in Donegal that were specificallyidentified via the county and local working groups.

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Work in the Development Phase

Deepening analysis andunderstanding of needs andissues

Capacity building of LocalGroups

Establishment of the CountySteering Group

Preparing Action Plans

Advancing the Education andLeadership DevelopmentStrategy

Other actions that were undertaken or begun in this phase included: an explorationof needs within day centres; acquisition of old computers for day centres andactive age groups; the development of an Active Age Handbook. Work also beganon the development of modules on leadership and advocacy; moving fromindividual to collective working - needs and actions, celebrating diversity amongolder people and inter-generational working. These were designed to be part ofthe capacity building programme for the local and county groups.

A training programme to train older people as facilitators and researchers wasdesigned with the Dept. of Public Health in the North Western Health Board.Unfortunately the training programme had to be curtailed due to budgetaryreadjustments in the Department, however, two sessions for facilitators have so fartaken place.

Outcomes of the Development PhaseFive Local Groups were consolidated in North West Donegal; North Donegal;Inishowen; East Donegal; South West Donegal / South Donegal. They hadagendas for action and would meet monthly.

The Steering Group was formally established and work begun on the developmentof a two year action plan to advance The Voice of Older People.

Stage 3: Community ActionThis stage involves moving needs into actions, ensuring the active involvement ofolder people in any developments, in partnership arrangements based on equality,and focused on targeting poverty and social disadvantage, reducing healthinequalities, lobbying, influencing policy and making real change.

County Group Action Plan developedThe county group established four sub-groups to advance a series of actionswhich it had prioritised under each of its priority action areas heading:

• Facilitating the exchange of information, communication and co-ordinationbetween groups in the County.

• Advocating the needs of older people.

• Influencing decision makers with respect to the needs of older people.

• Developing, in partnership with relevant actors, new projects as needs arise.

Actions that have taken place or are planned include:

• Linkages and access to decision making. The County Group are nowrepresented on board of two of the three Local Development Partnerships andwithin various sub-groupings, on the Community Forums of the CountyDevelopment Board and on the management group of the CommunityDevelopment Project. At a national level the group is represented on theSenior Citizens Parliament, Age Action and AGE Platform Brussels

• Linkages and information dissemination to local level. The group havedisseminated information to local level via the open days, media and workinggroup.

• A media group has been established with representation from each of theworking groups and county group. A Newsletter is planned and will belaunched in 2004. Media training skills incorporating radio, newspaper hasbeen designed and will commence in 2004, this training will be open tointerested older people, membership of an existing group is not a pre-requisitefor participation in the training.

• Associated Workshops with relative agencies. A number of workshopshave been organised and have taken place with relevant agencies and thecommunity and voluntary groups e.g. VEC, Day Centres, County Council,Local Development Partnerships.

• Applications have been made by the Steering Group for funding tosupport the development of the work, of particular importance is securingfunding to employ older people as co-workers on the project.

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Follow up on the initial Consultations at local level

Two full day events were designed and organised at local level by the Inishowengroup and the local group in East Donegal. They were hugely successful andattracted a phenomenal level of participation with 390 people attending theInishowen event and 320 attending the event in East Donegal. A huge effort wasmade by the local groups to encourage participation in the event with posters, inchurches, post offices, health centres, day centres; visits to nursing homes, dayhospital and other residential settings; the use of personal contacts to older peopleliving alone;and promotion of the event on local radio and in newspaper. Thisensured that both the work of the local groups and the event were well advertised.For the local groups who organised the events, the turnout and level ofparticipation in the days programme was an affirmation of the effort made toorganise a successful and worthwhile event. Keynote speakers addressed thetopics that were prioritised by the local group following the initial consultations.There were workshops to further explore the issues raised. There were a series ofplenary and workshop style events to meet the objectives of the day including apresentation of Age Rage, the drama on ageism designed and developed with twoActive Age Groups and performed by older actors, creative workshops on moneymatters, making a will, on rights and entitlements, on active citizenship, advocacy,health promotion, story telling workshops, and the celebration of older people inmusic and song. Refreshments were provided and transport was organised by thelocal development partnerships, with specially designated bus and car pick uppoints. 26 information stands were exhibited at the Inishowen event.

A questionnaire was circulated at each event to help the local group in its work, tohelp to further define issues, areas of concern and how and where people wouldlike follow up. Participants were asked to return the completed questionnaires totheir local day care centre. The managers of the local day care centres werepublicly introduced to the participants and were offered as points of further contactfor information and follow up in the interim. There was a 70% return ofquestionnaires.

Two more full day events will be undertaken by other local groups and will drawon the lessons of the first two days.

Local Groups current Priorities for ActionEach of the Local Groups has prioritised the key issue(s) identified through theconsultation process and the process of engagement with older people to date.Action plans have been developed to advance work in these areas.

" Inishowen has prioritised Social Isolation, Availability of information, ActiveCitizenship, Celebrating Older People, and is currently following up on bigconsultative event and preparing a six month action plan.

"East Donegal has prioritised Information, Social Isolation, Elder Abuse, andCelebrating Being Older. Elder abuse was named in the first consultation, itwas addressed by one of the key note speakers at the open day. It is a highlysensitive issue for many people and the group are considering exploring apiece of work, perhaps using drama initially to publicly raise and explore theissue. The group is encouraged by the success of Age Rage the dramadeveloped with two of the Active Age Groups about ageism. It has been a verypowerful tool for raising the issues and defining strategies for action.

"The North West Area Group which takes in Tory Island have prioritisedAccommodation and Housing, They are focusing on choices and rights aboutwhere you want your long-term care and where you get it. Their concern is withThe Voice of the Voiceless.

"South/South West Donegal local group has prioritised Housing andAccommodation and they are currently exploring the organisation of aConference in 2004.$-


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"North Donegal are still in the process of prioritising, however there is a majorconcern in the group arising from the consultations and their research aboutthe lack of opportunities for personal development, developmental educationand opportunities for social interaction for older people in care and in privatenursing homes. The big question that is being given attention by the group isWhose responsibility is it? The Health Board or the Community? How have wecreated dependency? These are the issues currently being explored by thegroup and that may lead to it defining a programme of action.

A huge issue for all of the local groups is the lack of transport and the difficulty thatposes for people who want to attend but who are unable to get to meetings. Oneof the local groups has re-organised itself and its meeting times and locations.Three more localised centres / meeting points have now been defined within thegeographic area the monthly meetings of the local group now rotate across thelocal centres. It has facilitated a greater attendance at meetings. It is expected thatthe other local groups may follow the example.

The Community Arts Strategy is currently being developed. The Arts work hasbeen tremendously important to date from a Community Work perspective. It hashelped fuel the enthusiasm, and the enjoyment of engaging with others in thechange process. It has a collective focus and has produced collective outcomes.It has been key in facilitating the identification and exploration of issues and indeepening analysis of the issues that need to be addressed. To date communityarts workshops have taken place in nursing homes and day centres, there havebeen a series of dance, music and story telling and creative writing workshops andprogrammes of events.

Age Rage a drama on Ageism - The play has been developed with two Active Agegroups and is being used as an educational tool with four schools, fourteen daycentres, five Active Age Groups, Women’s Groups and the local theatre. It hasbeen performed at all of the local consultations. The drama designed anddeveloped with older people and performed by older actors deals with pertinentissues e.g. health, relationships, anger, isolation, carers, transport, ruraldegeneration, post offices, family life etc. The drama has been filmed and willcontinue to be used as a training and awareness raising tool by the Project.

Local projects that have been developed

• A Cross border project based on a telephone networking service with atelephone link line for older people to combat fear and social isolation

• A Video on ‘Using your own Voice’ - this has been used as an educational tooland to support effective participation at workshops and conferences

• Information pack on ‘Who is doing what where?’ in the local area

• Community Arts Programme covering the county and being implemented invarious settings where older people meet or reside

• Development of a drop-in centre in association with a local communityplatform group

• An access project with the County Council who are tidying up roadways andbushes along pathways and sand dunes making them safe and accessable

• The formation of new Active Age Groups, encouraged and supported and peerled by older people who are currently organised in Active Age Groups

• Active Age Handbook

• Links to the Sports Partnership

Education and Leadership Development StrategyA series of ‘exploring issues’ life long learning education days were undertaken atlocal level with high attendance - up to fifty at each session. This intersectoralapproach is proving to be extremely successful - highlighting and linking issues,and offering and making it possible to develop alternative approaches e.g. theprovision of education and training in Day Centres. $(


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Leadership Training Workshops are currently being planned for Local Groups.Five two-day workshops will deal with ageism, pre-development issues, workingtogether and working creatively and will address the specific skills requirementsthat each of the local groups have defined as a priority.

A training programme is also currently being prepared for the Steering Group. Itwill involve training sessions with outside facilitators focusing on skills that arerequired to advance their work plan e.g. working with people, advocacy andlobbying, effective decision-making, negotiating skills, power and power-sharing,project management, funding and sustainability.

The education and leadership development strategy supports the initiatives indrama and community arts, the peer mentoring and the media skills developmentprogramme. The participative research training and the training for facilitators isongoing and is a key element in the education and leadership developmentstrategy (15 more sessions are planned).

A Healthy Ageing Programme is also being planned for 2004 which will emphasisethe social model of health. It will be concerned with health determinants andpromoting health and well-being.

Capacity Building for the Health Board SectorA training programme is currently being prepared for health board staff onCommunity Work with older people. It will be delivered in the autumn of 2003 bythe Community Worker and a number of the sessions will be co-chaired by one ofthe older participants of the Project. The health professionals in the HealthPromotion Unit clearly want to work with people in community but they do notknow how to do it. They have no experience or training in CommunityDevelopment and come from very different backgrounds and disciplines. It isimportant to clearly acknowledge that, and respect where they are coming from.Exploring the meaning of the principles common to health promotion andCommunity Development e.g. participation, power-sharing and empowerment,health inequalities, intersectoral working, provides a good starting point to helppromote good practice. An exploration of who carries and holds power, whodecides on the priorities and the agenda for action, what level of participation orpower-sharing is on offer can clarify what Community Work means in practice. andcolleagues can also be supported to target their work. The modules beingprepared deal with these and other issues.

Stage 4: EvaluationAims of the project with regard evaluation are to:

• develop an evaluation framework for the project• develop a model of work that has been tried and tested and that can offer

transferability of good practice

Monitoring, reviewing and evaluating progress in advancing the aims, objectivesof the Voice for Older People is an ongoing process. The experience of the projectis being documented. A formal evaluation will be undertaken with the support ofthe Health Board Health Promotion Unit and by an external independent evaluator.The evaluation model chosen is a combination of a participatory and a criticalqualitative approach, which as the process develops, integrates a bottom up / topdown approach (‘Community Capacity Initiative’).

The bottom-up approach with a focus on locally defined priorities andperspectives facilitates a process of mutual learning and analysis, which takesplace throughout the project, where people are brought into the process asowners of their own knowledge and empowered to take action.

The top-down approach acknowledges the need to incorporate the views,perceptions and culture of agencies and the process of change, which will occurin their movement and shift towards power sharing and active involvement ofthe community in decision making in achieving equity and social justice for olderpeople.

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Findings and lessons to dateA Voice for Older People has begun to give a voice to older people, it hasencouraged them to identify their real needs and issues, to collectively engage indevelopment opportunities and to engage in a process of social change. Manyhave seized the development opportunities with gusto. The older people areenthusiastic about the Project, they don’t beat about the bush, they have beenaround for a while, they know their issues and they are glad to get a chance tobecome actively involved in changing things and enjoying themselves at the sametime.

The Project has challenged views of ageing, has confronted ageism and hasbegun to introduce what Community Work with older people is really about and toshow what positive things happen when Community Work principles are applied inpractice.

The Project has raised the expectation of older people for a better quality of life,and has raised capacity to help make that happen. It has brought new energy intolocal communities. There has been huge learning and sharing from the processacross the local groups in the county and into and through the county group.

Drama and community arts have had a major impact and are a contributory factorto the success of the project to date.

Targeting particularly vulnerable groups needs strong positive action and is donewith the support of existing projects with a clear social inclusion and equality focus.

There has been a very noticeable increase in the level of attendance at day carecentres, however this is now coupled with a demand and the challenge for moreexciting developmental programmes and activities in such locations. In one centre,an Active Age Group was formed and then many of the day care participants leftto join in the more interesting Programme of the Active Age Group.

Since the inception of the Project, there is only one full time worker dedicated toits development. There are as yet no resources to employ others, especially olderpeople as co-workers on the project.

Working as a Community Worker within an organisation whose systemsand personnel are focused on service delivery has presented a number ofchallenges to date:

• “You can get isolated from other Community Development workers in the fieldbecause they feel that you have ‘sold out’ by going within the system to work”.There is a belief that Community Work can only be done outside the system.

• The lack of appreciation of the developmental process in Community Work,the lack of flexibility in the administrative system and reporting arrangementsundermine energy and the Community Development process. In the first yearof the project there was constant concern and criticism that the budget was notbeing spent on time, that spending was not on target for the quarter. “As yousee issues being identified and the process unfold you are reluctant to reporton what is happening because the action that might be prioritised by the olderpeople may not be that which was specifically named and costed in youroriginal action plan”. Community Workers need to find allies within the systemand work with them, their support is needed and helpful to raise the credibilityof Community Work in the early stages.

• The Community Work process has provided a big challenge and a hugelearning for the Health Promotion Department. The Health Board providesgrants to small local groups under the ‘Community Development’ heading.There was a particular perception of what Community Work is about andprobably a view that A Voice for Older People would be a relatively insignificantproject. “But the Project had a very different understanding of whatparticipation means and of course power-sharing is another value at the coreof the Project’s practice”. There was no expectation that the Project wouldmushroom or have such an impact. It has provided huge opportunities forlearning for everyone.

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• There is a need for Community Development training for health practitionersin the Health Board, especially those in the Health Promotion Department whoengage with local communities.

• There is a need for Community Development workers working within a cultureand an institution of service delivery to have a place for support, to have aspace to discuss the challenges they face, to bounce ideas, to maintain theirvision and clarity, so that they can engage effectively as Community Workersin surroundings that are not always supportive. The Community Workers Co-operative needs to continue to provide that space and act as a catalyst for newideas, analysis and strategies.

For Further Information ContactAnn-Marie CrossCo-ordinator, Voice for Older PeopleHealth Promotion DepartmentNorth Western Health BoardDromany ChurchLetterkennyCo. DonegalPhone 074 9178539email: [email protected]

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Elements of Good PracticeClear strategic focus to the project: vision" approach" values#

Project is placed in the social" economic and cultural reality of older people�slives#

A two pronged approach to affecting change is adopted# The Project

�is designed to be older people owned and led" they engage in the socialanalysis of needs and issues and in action planning to ensure change

�it acknowledges that change requires a service sector willing to act onidentified issues

The stages in the community development process are clearlyacknowledged

The importance of a baseline" data collection and assessment of needs andissues are recognised and addressed in the project

Progress indicators are established" there is ongoing evaluation"participatory appraisal and ongoing review of progress#

Findings and lessons to dateA Voice for Older People has begun to give a voice to older people#

It has challenged views of ageing#

It has raised the expectation of older people for a better quality of life" andhas raised capacity to help make that happen#

There has been a very noticeable increase in the level of attendance at daycare centres but with an expectation of more developmental programmesand activities#

Challenges for community workers working in the healthsector�You can get isolated from other community development workers in thefield because they feel that you have �sold out� by going within the systemto work�#

The lack of appreciation of the developmental process in community work"the lack of flexibility in the administrative system and reportingarrangements undermine energy and the community development process#

The community work process has provided a big challenge and a hugelearning for the Health Promotion Department#

There is a need for community development training for healthpractitioners#

There is a need for community development workers working within aculture and an institution of service delivery to have a place for support" tomaintain their vision and clarity#

Women’s Health Action, Cairde: MinorityEthnic Women Researching and Analysingtheir NeedsCairde is a non-government organisation working to reduce health inequalitiesamong ethnic minorities and is committed to supporting the participation ofminority communities in enhancing their health. Cairde works within the WHOdefinition of health which states that “....Health is a state of complete physical,mental and social well-being and not merely the absence of disease or infirmity.The enjoyment of the highest standard of health is one of the fundamental rightsof every human being without distinction of race, religion, political belief, economicor social condition...”

Cairde currently operates two programmes to achieve its overall aim.

1. Healthwise Community Impact is an information and capacity buildingprogramme which seeks to build the capacity of ethnic minority communitiesand organisations to respond to the health needs identified by theircommunities.

2. Women’s Health Action is a Community Development programme workingwith women from ethnic minorities to enable them to address issues whichaffect their health.

Core components of both Programmes include outreach and liaison with ethnicminorities, capacity building and development work with ethnic minoritycommunities and organisations, advocacy and support to individuals andcommunity organisations, lobbying and policy development. A Resource Centreoffers a vast range of supports to the work. The staff team are multi-lingual.Cairde’s own literature and information is available in English, Arabic, Russian,and French. Ethnic minority organisations are supported to adapt and translate theresource centre’s materials to meet their own communities needs

What is Women’s Health Action?The aim of Women’s Health Action is to enable women from ethnic minorities toaddress health inequalities.

The objectives set out to achieve this aim are:

• To support women from ethnic minorities to identify their health needs

• To build the capacity of women from ethnic minorities to collectively addresstheir health needs

• To raise awareness of the issues affecting the health of women from ethnicminorities

• To support women from ethnic minorities to influence policies which impact ontheir health

• To support women from ethnic minorities to build solidarity with other groupsexperiencing inequality.

The analysis underpinning the approach adopted by the ProjectWomen’s Health Action is built on the premise that health is an equality issue(equality in terms of outcome/condition) and it adopts Community Work as a toolto enable women to address inequalities in the area of health. Women’s HealthAction works with a structural analysis of health inequalities and with theunderstanding that policies, procedures and practices, or lack of, set out byinstitutions and policy makers cause, contribute to, and/or exacerbate inequalitieswhich impact on health inequalities.

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Cairde established an EthnicMinority Health Forum in thepast year to build thecollective capacity of ethnicminority organisations# Itsmembership is open tograssroots ethnic minorityorganisations and theycollectively identify healthneeds in the networkingprocess# The Forum�ssuccessful application for agrant from the CombatPoverty Agency BuildingHealthy CommunitiesProgramme will enable it todevelop its capacity buildingprogramme focused onbuilding the capacity of themembership organisations toparticipate more effectively ina collective way in the healthforum# The Programmeincludes developingunderstanding of communitydevelopment" understandingof health policy and the Irishhealth system" thedeterminants of health andthe causes of healthinequalities in Ireland" policyand lobbying skills#

The Project is strategically focused on three areas:1. Outreach and Advocacy Work

• Outreach to hostels, churches, community centres, through otherorganisations

• Drop-in resource centre• Advocacy and support work in the areas of accommodation, education,

welfare rights, immigration, asylum, work permits, health• Documenting issues, analysing the issues that need to become the

cornerstone of policy development

The outreach work provides the first point of contact with ethnic minoritywomen. It also provides opportunities to build trust, identify issues, inviteindividuals to combine with others to address the needs identified and itprovides insights and identification of the needs and issues that need to beaddressed in policy formulation.

2. Group Development / Capacity Building WorkWomen’s Fora• Women’s Support and Development Group• Developmental and capacity building work in: Clondalkin; Blanchardstown;

Kimmage/Walkinstown/Crumlin/ Drimnagh; Tallaght• Developmental work with Ethnic Minority Cultural Centres and Projects

(Islamic Cultural Centre, Russian Speaking Women’s Group Slavianka)Information• Welfare Rights Sessions and Welfare Rights Fora• Production of materials on Rights and Entitlements

The development and capacity building work provides the opportunity toidentify needs, to make a social analysis of issues, to establish priorities foraction and to develop the knowledge, skills and capacity of ethnic minoritywomen to act collectively to address needs identified. It also provides theopportunity for leaders to emerge who will participate in policy developmentand lobbying, other working groups, networks and fora.

3. Lobbying and Policy Development

Developing an analysis of Health Inequality• National Consultative Committee on Racism and Interculturalism -

Women’s Committee• Platform Against Racism• Community Workers Co-operative Health Sub-Group• National Women’s Council of Ireland

Building Solidarity and collective action about issues• Integrating Ireland• Ethnic Minority Health Forum• Inner City Organisations Network / North West Inner City Network / RAPID

/ Dublin City Development Board - Community Forum• Ireland En Route

Influencing policy• Women’s Health Council• Eastern Regional Health Authority

Social InclusionEthnic MinoritiesWomen’s Health UnitSexual Health

• Women’s Health Advisory Committee• Dept of Health and Children - Women’s Health Policy Unit• Reception and Integration Agency.

In the initial stage of the project the lobbying and policy development wasstaff led with women who were engaged in the projects being supported toparticipate and enhance their skills and confidence in the process.

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Shifting the Focus of a Health Promotion and PreventionProgramme to a Community Work Project focused onAddressing Health InequalitiesWomen’s Health Action grew out of a HIV prevention programme. There are twoaspects to Women’s Health Action’s programme. The first focuses in general onthe health needs of ethnic minority women per se. The second aspect, the focusof the case study, is the Women’s Support and Development Group which is aforum for minority ethnic women living with HIV.

Cairde wanted to bring a Community Work approach to the work of theProgramme, to build the capacity of women to identify and analyse their ownneeds and the needs of other HIV positive women, and to build the confidence andorganisational capacity of women to impact on policy development.

Identifying an approach to the workWork began with the need to look at Community Development responses to theneeds of HIV positive women, with a need to make an assessment of what the realissues were for women, and to explore how best to respond to the needsidentified.

In discussions with women who were using Cairde services, ethnic minoritywomen identified that they were having difficulty accessing HIV services, wereexperiencing racism within the Irish hospital system and society, they were havingdifficulty registering with GPs, they had poor accommodation or had problemsfinding accommodation. Many were living in poverty. There were a whole range ofdifferent issues impacting on their overall lives rather than just HIV.

A review of the research in the UK indicated that given the stigma experienced byAfricans, HIV projects per se can experience difficulty, people would just not cometo a clearly identified project. Most of the women with whom Cairde had contactwould have had direct experience of a relative being isolated or rejected by theircommunities because of their HIV status. They feared disclosure of their own HIVstatus.

To appropriately respond to needs, Cairde would have to broaden its perspective.The real challenge in reality was to address health inequalities, women’s healthand health related issues, one of which might be HIV. All the issues faced by thewomen were of exclusion and poverty, and issues pertaining to health and healthinequalities rather than about one illness.

From the outset therefore, the Women’s Support and Development Group wasconceived and designed as a Community Work intervention with women fromethnic minorities living with HIV to address their health and health related needs.HIV was a health need of women.

The Initial Stage of Forming a GroupA Women’s Health Development worker was employed. Work began with a groupof seven to eight African women who had met for a couple of coffee mornings. Nowomen’s group existed and no developmental work had been previouslyundertaken with the women. Each woman was invited to participate in the settingup of a Women’s Support and Development Group. It became very apparent thatthere were huge issues about the stigma of HIV, each of the women was living interror of being seen by others, of disclosure. An enormous amount of worktherefore was required to build trust and in getting to know the women before theywould even agree to meet in a group. When the group met, they discussedexperiences. They met weekly. There were huge issues about fear, stigma.

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Personal Development and the many barriers to participationAfter six months of meetings it was decided to organise a personal developmentcourse. Concern was expressed by the project director that the group were ineffect reinforcing their fears in the discussions. The course ran for twelve weeksbut it was necessary to provide an extension to the course, in effect a second sixweek personal development course, to facilitate women who found it difficult toattend all of the original sessions as organised. A lot of the women were in crisissituations and there was endless disruption in their lives. Women were movinghouse every six to eight weeks, because they were being evicted. Other womenwho had been in direct provision and had been told that they could move out, werelooking for accommodation and were finding it difficult. External factors had amajor impact on women’s ability to organise their time.

The level of stigma that the women experienced continuously manifested itself inthe early stages of the Programme. All of the women were extremely cautiouseven of the facilitator of the course. A lot of the personal development programmefocused on their own reaction to their own HIV diagnosis which was a barrier tothem participating in a lot of other activities. None of the women had everdiscussed their positive HIV diagnosis before, they had never shared theirexperience with any other women, ever.

Many women perceived themselves as inferior and perceived other HIV positivewomen as inferior, the level of self-stigmatisation was high.

Apart from the fears and stigma felt about HIV, the women’s self-esteem wasdamaged by the amount of time that they spent in their lives managing poverty andcrisis. The success in creating a space where seven or eight women werecomfortably sitting in a room and laughing and joking, had a very powerful impact.It was a first time experience for many of the women.

The different and diverse needs of local Irish women and Minority EthnicWomenThe discussion in the personal development sessions identified the different anddiverse needs of local Irish women and minority ethnic women. An interculturalproject for women was initially considered but the experiences of the women anda number of the issues raised in the discussions cast doubts about theappropriateness of such a project in addressing the different and diverse needsbetween and amongst a very mixed group of women.

A lot of the HIV services in Ireland, especially for women, are particularly targetedat women from particular socio-economic backgrounds with a drug using history.Post diagnosis counselling is generally targeted, the assumption is that you are adrug user. The counsellors based in the community are addiction counsellors. HIVservices are all based in drug treatment clinics. HIV Community Welfare Officersare also located in the drug treatment clinics. None of the women participating inthe Women’s Support and Development Group were drug users. Many of theAfrican women were in monogamous relationships and would have been infectedwith HIV by their husbands or partners.

Racism was a constant experience for the African women and the level of racismdirected at them by many Irish women was experienced as very high. The Africanwomen had very clear concerns, preoccupations and priorities focusing aroundasylum, immigration, family reunification, issues that would not be a priority forIrish women.

Identifying the Needs of Minority Ethnic WomenIt was decided to undertake a participative action research project on the needs ofHIV positive women from ethnic minorities in Ireland. Much of the research on theneeds of HIV positive women in Ireland indicates that HIV is related to drug use,and indicates low levels of education amongst women, poor housing andaccommodation, long-term unemployment. These indicators / factors are notautomatically applicable to minority ethnic women in Ireland.

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Skills development in project planning, research and social analysisTraining objectives and research objectives were established for a ParticipativeAction Research Project that would be undertaken over a six month period. Thewomen trained and they developed research skills. They designed thequestionnaires, they did a lot of role play on how to interview people, they pilotedthe questionnaire, coded the questionnaire, they inputted the data into thedatabase and then analysed the findings. While a wide range of issues andfindings arose with the pilot questionnaire, the women acknowledged that furtherissues would emerge when the research would be undertaken.

To effectively analyse the findings and prepare recommendations that wouldimpact on policy it was proposed and agreed to undertake training in socialanalysis. Such training would support and enable the women to more effectivelydevelop an analysis of the issues arising and focus the findings from theirresearch. Eight workshops were organised with an external facilitator on differentthemes, the main themes were power, racism, gender. It was important that thewomen could make a social analysis of incidents of racism and be able to relatethat to a policy context: that they would be able to explore and understand sexism,globally and locally, how it is manifested, how it affects and impacts on women,why and how unequal relationships and partnerships are constructed, developedmaintained and sustained.

Selecting the interviewees for the ResearchThe eight women interviewed 49 women over the six month period of theParticipatory Action Research. The women spend a lot of time sitting in waitingrooms. Over the course of a year they may get to know others and eventually theymight share information. That is how friendships or contacts between womendevelop. Some of the interviewees were women known to the participants of theWomen’s Support and Development Group in these circumstances. Some ofthese women in turn introduced them to another woman. A number of the womentook the risk of opening up to other women previously not known to them. Most ofthe women interviewed three or four women, one interviewed eight women, theywere not allowed to interview each other.

The Expected outcomes of the first and second stage of the ProjectThat whole process was about building up a women’s group to start off with,creating a space for minority ethnic women to explore their needs. It was aboutdeveloping their capacity: to meet other women and to systematically explore withthem their needs and their experiences; to collate and analyse all of theinformation and data gathered in the research; to prepare a report / strategydocument that would document and present the reality of life for HIV positivewomen who don’t fit into the Irish drug using background; and then finally to usethat strategy document to develop and outline a plan of action for the next numberof years.

By participating in the research process and the social analysis skills training, thewomen would understand where the findings were coming from, they would ownthe findings and they would have defined and owned the agenda for action.

The Action Plan will cover the following areas:• Health Services;• Accommodation;• Racism;• Education and Training;• Employment and Finance;• Immigration.• Safety and Living Environment;• Spiritual Life;• Access to Support Services; and• Childcare.&-


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The first five action areas were identified at the beginning of the project. Howeverduring the preparation of the questionnaire the women identified the latter fourareas for research questions and as key areas for action.

The Action Plan will outline, under the key headings above, a series of actions andsub-sets of actions that will need to be undertaken by each of the following:

• The Women’s Support and Development Group,• Cairde• Government Departments.

The main activity of the Women’s Group in the future will be to implement thatAction Plan, and based on the findings of their own research.

Some indications of the types of actions to be undertaken by the Women’sSupport and Development GroupThe report is currently being prepared, the findings will then be analysed and theAction Plan drawn up. There are some indications of the types of actions that thewomen will identify for themselves arising from the findings of their research.

In relation to Racism, women feel that there is a lot of mis-information about theneeds of asylum seekers, that they are continuously being disparaged by rumoursbeing spread about them being given cars by social welfare, and by press articlessuggesting that African women are bringing HIV to Ireland: that all women areinfected and are spreading the infection. They feel they can highlight their storiesin booklets and use that to inform and make others more aware of the reality ofliving with HIV in Ireland.

They are concerned about institutional racism. They wish to engage with theReception and Integration Agency who appear to have a public health agendawhich may reinforce peoples prejudice about ethnic minorities and health statusso that when people think of health and ethnic minorities they think of malaria, TBand disease control.

They see themselves engaging with service providers and health officials, havingmeetings with social workers and being able to suggest how HIV clinics can bemade more accessible to non-Irish people, meeting with Public Health Nurses,and meeting with Community Welfare Officers about the inappropriateness ofproviding services in drug treatment clinics.

Another practical project resulting from the findings of their research is theprovision of health information. Many women interviewees were not aware thatHIV medication is free in Ireland, others were not aware of the benefits of takingtreatment: that it reduces the transmission of infection to a partner, or inpregnancy, and that you live longer. The women will prepare an information leaflet,encouraging women to test, advising on the availability and the benefits oftreatment and telling their experiences of the benefits of medication to them andwhat changes taking medication has made to their lives.

The Women’s Group are clear about the importance of their own programme ofwork arising from the research and of the importance of the action plan and theproject based work that can be undertaken with the support of Cairde. They alsoknow that they will continue to strategise so that their lobbying work can beeffectively undertaken.

The Action Plan is strategically focused. The actions that will be undertaken by theWomen’s Group will be reinforced by the Actions to be undertaken by Cairde. Theissues which it raises will be named and recommendations will be reinforced at alllevels. The issues and recommendations will also be presented to practitionersand policy makers in state agencies and departments where they can besupported and pushed from the bottom up and the top down to initiate change andeffective policy development. &(


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Lessons learnt to date at the local/community level• Using Community Development as a tool to enable women to address

inequalities, and being committed to working clearly and openly withCommunity Work principles was key to the success of the project to date.

• A belief in the women and their ability to move from a situation ofpowerlessness to one where they could be agents in a change processwas held by staff and facilitators and was the essential element in the process.

• Keeping an eye on both the process and the task at all stages was crucial- this was evident through this phase in the process

" the personal development," the capacity building and formation of the group," the social analysis," the participatory research and" the development of an agenda and strategic action plan that the women

will take forward over the next few years so that the work can impact onpolicy and policy development & produce greater health outcomes.

• The extensive capacity building for the women is viewed as a critical factor ofthe projects success to date. In a lot of ways, the pre-development phase anddoing the personal development course was crucial. The level of stigmathat the women have and do experience should never be underestimated.

• The social analysis training allowed and facilitated the women to make moresense of their world and to question and challenge accepted ways of viewingthe world, it allowed and facilitated them to develop their critical consciousnessin a context of respecting difference and diversity amongst people andcultures.

• The capacity building through the personal development course and thesocial analysis skills training provided the women with the personal skills andthe confidence base to undertake the research. Furthermore, it equipped themwith the critical and analytical skills necessary to identify, articulate andanalyse the issues and problems presented in the research, to define theresponses which could most effectively address these needs, and makerecommendations that could impact on policy development that would producebetter health outcomes.

Lessons to date at the policy level• There is a constant problematising of the health needs of ethnic minorities i.e.

starting from the perspective that there is a problem.

• There is a predominance of negative stereotypes regarding health care amongethnic minorities, usually focusing on disease control rather than broad healthneeds. This stereotyping is manifesting itself in direct and indirectdiscrimination and racism, often within the health system and in Irish society.

• There is a very poor understanding of equality, of the concept of equality, ofhow inequality is generated and sustained in institutions, or of what a strategyto promote equality might entail.

• Health inequality is not seen an equality issue.

• There is a lack of recognition of Community Work or the legitimacy ofCommunity Work in addressing health inequalities. The medical model ofhealth is dominant.

• There is a lack of data pertaining to the ethnic minorities.

For Further Information ContactStephanie WhyteManager, Women’s Health Action ProjectCairde19 Belvedere PlaceDublin 1Phone 01 8552111E-mail [email protected]

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Actions

�Outreach and advocacy work

�Group development and capacity building work

"Personal development

"Skills development in project planning" research and social analysis

�Agenda setting" action planning

�Lobbying and policy development

"Developing an analysis of health inequality

"Building solidarity and collective action about issues

�Influencing policy

Elements of Good Practice

�Clarity of vision" values" approach and methodology# Clear emphasis oncommunity work as a tool to enable women from ethnic minorities toaddress inequalities in the area of health# Emphasis on both the processand the task of community work#

�Focus on development and capacity building opportunities that enableethnic minority women to identify needs" make a social analysis ofissues" establish priorities for action and act collectively to address needsidentified# The process and encourages and facilitates leaders to emergewho will participate in policy development and lobbying andnetworking in other fora#

�Emphasis on documentation and analysis of needs and issues that needto become the cornerstone of policy development# Project works with astructural analysis of health inequalities#

�Starting point is solidarity" and the project further supports womenfrom ethnic minorities to build solidarity with other groupsexperiencing inequality#

�Strong policy focus#

�Connections and networks within the community sector locally andnationally to deepen analysis" share experience and strengthen thecommunity sector#

The Traveller Primary Health Care ProjectUsing Community Work Approaches within a Modelof Health Service Delivery to Marginalised &Disadvantaged Communities

Pavee Point is a non-governmental organisation committed to the attainment ofhuman rights for Travellers. Pavee Point has been involved in direct work withTravellers since 1985. Innovation has been a key feature of the work done basedon a Community Work approach on an intercultural model and on aTraveller/settled community partnership. The group seeks to combine local actionwith national resourcing, and direct work with research and policy formation.

What is Primary Health CarePrimary Health Care has been identified and used as an approach to health carein the developing world. In the past 20 years there has been a growing interest inand a demand for such a service in the developed world as evidence from studiesindicate that the expanding marginalised populations here are sufferingdisproportionately from poor health and have less access to health care services.The concept of Primary Health Care (PHC) was established at the jointWHO/UNICEF conference in Alma-Ata in 1978. It acknowledged the need toreform the conventional health systems. Health was no longer regarded as amatter for health bureaucrats but the concern of society as a whole.

“Primary Health Care (PHC) is essential health care based on practical,scientifically sound and socially acceptable methods and technology madeuniversally accessible to individuals and families in the community through theirfull participation and at a cost that the community and the country can afford tomaintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, ofwhich it is a central function and main function and main focus, and of the overallsocial and economic development of the community.

It is the first level of contact of individuals, the family and community with thenational health system, bringing health care as close as possible to where peoplelive and work, and constitutes the first element of a continuing health careprocess”.

(Alma-Ata Declaration 1978)

Primary Health Care is a statement of health philosophy, it is not a package, or acomplete defined methodology. It is a flexible system which can be adapted to thehealth problems, the culture, the way of life and the stage of development reachedby the community.

Primary Health Care in communities means enabling individuals andorganisations to improve health through informed health care, self help and mutualaid. It means encouraging and supporting local initiatives for health.

Successful primary health care projects have emphasised a process that valuesempowerment, partnership and advocacy when designing and implementinghealth care interventions. This allows the partners to highlight inequity andnegotiate solutions with their relevant partners. Community participation and inter-sectoral collaboration are key to the success of Primary Health Care.

Background to the Traveller Primary Health Care ProgrammeCapacity building and empowerment have been core factors in the earlydevelopment of the Primary Health Care approach to Traveller health care. In1992 a group of Traveller women undertook a personal development course inPavee Point. The course which was supported by FÁS, was designed to introduceand sample skills which would enable Traveller women identify areas for furthertraining with a view to employment possibilities.

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The younger women who completed the course were particularly interested infurther training in childcare. However, the older women, many of whom had rearedlarge families and were grandmothers, identified health as a priority area that theywanted to tackle. They indicated that they wanted to improve the health status ofTravellers, and were interested in developing skills and acquiring information,particularly on the cause and prevention of illness among their community. Tofacilitate the development of an appropriate response to this request and theserious health needs of Travellers, Primary Health Care was identified as anapproach that could be piloted to facilitate Traveller participation in health.

At the completion of the course a proposal for a Health and Childcare Promotionfor Traveller Women was submitted to FÁS. The proposal noted that theexperiences and skills developed as participants on the New Opportunities forWomen (NOW) Programme enabled the Traveller women to identify health andchildcare promotion as areas for further skills development and in the long-term forincome generating possibilities.

The course was supported and 16 women undertook the course for a 30 weekperiod. Following the course a submission was made to the Eastern Health Boardfor funding for a Primary Health Care Initiative for Travellers. Funding was notavailable at the time and FÁS agreed to fund a further 30 week trainingprogramme under the NOW Programme.

Influencing the Policy ContextIn 1993, the Department of Health began a review of the Health Services with theobjective of developing a National Health Strategy which would identify and targetcertain groups who are known to be disadvantaged in various ways and whosehealth is shown to be adversely affected. Pavee Point prepared a detailedsubmission Towards a Health Strategy for Irish Travellers and presented it to theDepartment of Health. The submission was drawn up in consultation withTravellers through a number of workshops and discussions and it was also basedon research which set out to identify and document key issues and makerecommendations to the proposed strategy. Among the recommendations madewas the development of a primary health care service where Travellersthemselves are trained as primary health care workers. It noted that a proposal toestablish a Traveller Health Promotion Service was under discussion with theEastern Health Board.

The National Health Strategy report was published in 1994. The commitments thatit contained in relation to Travellers health facilitated Pavee Point’s preparationand submission of a proposal for a Primary Health Care Project for Travellers tothe Eastern Health Board.

Rationale for a Travellers Primary Health Care ProjectTravellers require special consideration in health care because:

• They are a distinct minority ethnic with different perceptions of health, diseaseand care needs

• The Health Status Study 1987, has shown that Travellers have different healthand disease problems to settled people. Infectious disease control, accidentprevention, ante-natal care and childspacing, genetic counselling, healthbehaviour and health service utilisation are all priorities that must beaddressed. The study also showed that:

"Traveller infant mortality rates is three times higher than the nationalaverage

"Traveller men had a life expectancy of 65 years - 10 years less than thatof settled men

"Traveller women had a life expectancy of 12 years less than settledwomen

"Travellers have higher death rates from all causes of death among thesettled community.

These distinct characteristics imply that innovative approaches to service deliveryare required if health conditions are to be improved.

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The Primary Health Care for Travellers Project was established as a jointpartnership initiative with the Eastern Health Board and Pavee Point with technicalassistance initially being provided by the Department of Community Health andGeneral Practice, Trinity College Dublin. The project began as a pilot initiative inOctober 1994 in the Finglas/Dunsink area of Community Care Area 6 and withfunding from the Eastern Health Board. It had the following objectives:

• Establish a model of Traveller participation in the promotion of health

• Develop the skills of Traveller women in providing community based healthservices

• Liase with and assist in creating dialogue between Travellers and HealthService providers

• Highlight gaps in health service delivery to Travellers and work towardsreducing inequalities that exist in established services.

Partnership ModelThe project which was carried out as a partnership between the Travellers, PaveePoint and the Eastern Health Board was the first of its kind in the country. It wasacknowledged early as a model of good practice. It facilitated significantconsultation between Travellers and service providers, greater informationcollection and sharing and improved access and utilisation of services. Thedifferent strengths and resources of the statutory and the community sector,brought together in a constructive way on an agreed agenda, had more impactthan if either operated in isolation.

Each partner brought different skills to the project: Pavee Point provided thechannel of communication and established trust with Travellers, an arena forTraveller participation and a Community Development approach to working withTravellers; the Health Board provided the funding, the health knowledge and thehealth professionals.

Co-ordination and management structureThe partnership model of working was reflected in the co-ordination andmanagement of the project.

A public health nurse was assigned to the project by the health board and aCommunity Worker by Pavee Point. The range of skills that each brought to theproject contributed to its success. A balance between health and CommunityDevelopment was reflected in the staff backgrounds and was particularlyappropriate in the development of the Primary Health Care approach to healthissues. The co-ordinators were jointly responsible for the co-ordination anddelivery of the project on a day to day basis and they were responsible forconvening and resourcing Steering Group meetings.

The project was managed by a Steering Group which included representatives ofthe Eastern Health Board, Pavee Point, the Project Co-ordinators and twoTraveller Community Health Workers one permanent and one rotating. A crucialingredient for this partnership was the willingness to dialogue, as equals, whilerespecting each others roles, responsibilities and ethos.

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Outcomes and conclusions at the end of the Pilot InitiativeOn a practical level, project reports record that significant progress was made inrelation to:

• The capacity of the Traveller women who were employed as CHWs and thedevelopment of their skills in relation to health needs assessment; healthplanning and prioritisation and health promotion work;

• The gathering of information by CHWs on the health status; the causality ofthe poor health of Traveller families on the seven project sites; on the healthservice personnel and services used by these families and on disease patternand uptake of health services.

• The development of an intersectoral collaboration in the co-ordination andmanagement of the Programme.

• A considerable impact was made on Travellers and Traveller organisationsaround the country about the potential of health initiatives among the Travellercommunity

• Greater awareness was created among health service practitioners and policymakers about Traveller culture, the specific needs of Travellers and thepossibilities regarding service improvements.

In June 1995, the Department of Health published a discussion document‘Developing a Policy for Women’s Health’ which acknowledged the impact of pooraccommodation on premature mortality and morbidity among Traveller women,and stated that Travellers should be provided with houses for those who wantedthem and that serviced sites should be provided for those who wished to retaintheir traditional way of life. It also stated that Health Boards should ensure thathealth services are provided to Traveller women and children.

In 1995, the Report of the Task Force on the Travelling Community was published.In the chapter on health, recommendations were made on a range of Travellerspecific services. Overall the Task Force recommendations were an affirmation ofthe PHC project’s work and in particular of the contribution it was making to anoverall development of Traveller health services.

In the light of positive evaluations the project was continued for four years.Following its implementation report 1996-1999 the Primary Health Care Projectmoved into a new phase of development and innovation. Now in its tenth year theProject in a dynamic way continues to respond to needs, using Community Workapproaches, developing an intercultural model, a partnership approach andcombining national action with national resourcing, and direct work with researchand policy formation.

In 2002, ‘Travellers Health - A National Strategy 2002 - 2005’ was launched.As recommended by the Task Force in 1995, a National Travellers Health AdvisoryCommittee was established in 1998. This committee is representative of theDepartment of Health and Children, the regional health boards and the nationalTraveller organisations. This committee worked on the production of the NationalStrategy for four years.

‘Travellers Health - A National Strategy’ is highly significant in that it represents achange in national policy towards Travellers. It firstly recognises Travellers as adistinct minority ethnic group in Irish society with a health status far below themajority population and having specific health needs. It also recognises that socialexclusion, racism and living conditions have an impact on health status. Thisreport and its recommendations are welcomed by Travellers and Travellerorganisations nationally, who participated and contributed significantly to thedevelopment of this strategy.

The strategy contains 122 actions which are to be implemented over a four yearperiod, from 2002 to 2005. € 8.3 million has been allocated for the implementationof these proposed actions. +&


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The Interventions and Outcomes from the Project include:1. General:

• The Project has continued for nearly 10 years. It has expanded to cover theBlanchardstown area and now works with over 250 families in the Finglas andBlanchardstown area.

• Currently there are 14 women and 2 men employed as Community HealthWorkers (CHWs).

• Training continues on an ongoing basis to ensure a flexible response byCHWs to the communities needs.

• The PHC Project for Travellers model has been recommended by the NationalTraveller Health Strategy where there is a significant Traveller population.Twenty eight projects are currently replicating the model around the countrywith support from Pavee Point Health Team. CHWs from the Project havebeen involved in visiting or receiving other Projects to share experiences andhave been part of interviewing process for some projects.

2. Research

• The first Traveller needs assessment survey carried out by the TravellerCHWs, identified the health needs of the Traveller community in CommunityCare Area 6. The results of the survey and focus group discussions with theTraveller community and service providers resulted in amongst other things,the planning and implementation of culturally appropriate interventions inpublic health nursing; oral health; nutrition; audiology; environmental health.

• A further survey was carried out seven years later. The new survey allowed adetailed analysis of current and new needs and an impact assessment of thework and the outcomes of the Project over the past five years in addressingthe needs identified in the last survey. It also informed the work currently beingundertaken by the Project.

• An All-Ireland Traveller Health Needs Assessment and Health Status Study, iscurrently being designed and will commence in mid 2004. This majorNorth/South initiative is being specifically designed to engage Travellerorganisations at all levels of the research and in the data collection. Aconsultation process regarding the design of the study has been completedwith all stakeholders, and the PHC for Travellers Project input wasincorporated.

• Research has been undertaken on Traveller women’s reproductive health,mental health and the environment where the PHC Project for Travellers werekey informants.

3. Production of culturally appropriate training materials.

• Culturally appropriate health education materials are been designed by theProject on an ongoing basis.

• Posters have been produced covering topics such as: Travellers HealthStatus, breast feeding, care of burns, nutrition and oral health. The postersprovide key messages in a culturally appropriate way, they increase visibilityof Travellers in education materials. These materials are displayed in surgeriesand clinics nation-wide, and are used as training tools by replicating projects.

• Two videos, with accompanying training booklets, have also been produced bythe Project: Pavee Beoirs ‘Her Reproductive Health’ and Pavee Gailles‘Traveller Children’s Health’. These initiatives developed through trainingcourses organised for CHW training on women’s and children’s health. Thelearning was used to produce culturally appropriate videos which were thenpiloted and seen to be culturally acceptable.

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• Given the low literacy levels of adult Travellers, the PHC for Travellers Project,produced an information video on the National Traveller Health Strategy. Theaim was to ensure Travellers and local Traveller Groups, but particularly thosewith literacy problems were informed about the recommendations of NationalTraveller Health Strategy and how it proposed to improve of Travellers health.The video facilitates an analysis by Travellers themselves as to the issuesfacing their community and will enable them to collectively campaign for thefull implementation of the Health Strategy and its proposed actions.

• Health education sessions are prepared and delivered by the CommunityHealth Workers on site. The regular presence of CHWs on site, has madehealth information more accessible and culturally appropriate, allows space fordiscussion and explanation, and addresses the language and culture gapsthat exist.

4. Targeted initiatives

• Well-women clinics specifically targeted at Traveller women have beenorganised. These clinics facilitated access for the first time for Traveller womento breast screening and family planning facilities. These special clinics aresupported on an interim basis while Traveller women build up confidence andknowledge of the service. Community Health Care Workers make blockbookings for groups of Traveller women and accompany them to the clinic.Many women are now independently accessing the service. The Projectcontinues to lobby for this level of service in the local area.

• The Project liaises with Breast Check to ensure that all Traveller women in thetarget age group are included in the invitation for screening. Clinics dates arearranged if necessary.

• Traveller men’s health is the focus of a number of pilot initiatives in responseto the identification and exploration of men’s participation in their health care.The recent inclusion of two men training as CHWs means that the Project willbe able to take more initiatives around men’s health.

• Other targeted initiatives include: Audiology services, dental services, speechand language therapy, child development clinics, where CHWs identify andaccompany families, facilitate sessions with health service providers andprovide follow up and support.

5. Increasing Awareness of Traveller health needs

• There is much greater awareness about the needs and entitlements ofTravellers in the Health Service as well as the difficulties in accessing servicesthat should be available.

• In many Health Board areas Public Health Nurses (PHNs) have beenspecifically designated to work with Travellers, they are engaged in directservice provision to Travellers of all ages and both sexes including PrimaryHealth Care, and interventions such as advice, nursing diagnosis and referral.In areas where there is a Primary Health Care Project, PHNs are engaged inthe delivery of health promotion/prevention services in partnership with theCommunity Health Worker. Regular co-ordination meetings are held.

6. In-service training

• The provision of in-service training to a range of health professionals aims toencourage health personnel to offer a more culturally appropriate service andwork towards an increase in the utilisation of essential services. The trainingprovided by the CHWs, provides a mechanism to challenge racism anddiscrimination at both individual and institutional level with in the healthservice, as well as cultural awareness raising. In service training is provided inhealth environments such as hospitals, and Universities, to a range of serviceproviders (approximately 300 per year) including GPs, physiotherapists, familytherapists, medical students, public health nurses and student nurses.

• Each year there are on average 12 student nurses on a one week placements.

• The project also accommodates placements for Community Work studentsfrom Maynooth, NUI, on a regular basis.

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7. Representation

• Presentations have been made at a number of local, regional, national andinternational conferences by the Project.

• The Project has used its networks and solidarity work with other communitysector and equality interests to raise further awareness of Traveller healthneeds and to disseminate the lessons from the Primary Health Care Project.

8. Extension of the model

• The work of the Project has been replicated. There are now 28 Primary HealthCare Projects throughout the country, some well established, others are inearly stages of development.

• Traveller Health A National Strategy 2002-2005 outlines Dept. of Health andChildren policy and proposed that:

"Primary Health Care for Travellers Projects should be developed inconjunction with Traveller organisations in all health board areas wherethere is a significant Traveller population by 2005. The Department ofHealth and Children will provide funding to allow for the freeing up of staffand other resources on the part of appropriate organisations in order toimplement a suitable strategy for replication of the Projects in relevantareas.

"Each Primary Health Care for Travellers Project will have two co-ordinators, a relevant health professional, employed by the Health Boardand a Community Health Worker employed by the Traveller organisation.

" In developing the Primary Health Care for Travellers Projects there will bean emphasis on flexibility and innovation in order to respond to differingcircumstances and differing health needs as identified by Travellers ineach area.

"The Projects will be periodically evaluated and progress reports madeavailable to the Traveller Health Advisory Committee of the Department ofHealth and Children

"As they are developed the Projects will be used as a resource to trainHealth Board professionals in anti-racism skills, Traveller culture and goodpractice in addressing Traveller health needs.

"The Department of Health and Children will support an annual conferenceto share experience and learning of Health Care for Travellers Projects.The first conference, on Traveller Health Units is being planned for 2004.

9. Advocacy and Lobbying

• Advocacy and lobbying are core actions of the Primary Health Care Project. Inorder to lobby for the policy changes needed and to promote the recognitionof the special needs of Travellers and their inclusion in all mainstreamprovision, numerous submissions, policy papers and reports have beenprepared by the Project.

• At international level the Project links with Roma Gypsy Groups through theSASTIPEN Network, Council of Europe Roma Rights projects, InternationalRoma Women’s Network and Scottish Travellers. The Project is involved in anumber of trans-national initiatives, which provide opportunities to work with,share ideas and develop analysis with Roma, Gypsy and Sinti organisations.These initiatives also facilitate the expression of solidarity between groups andprovide opportunities to advance equality, inclusion and health agendas at EUlevel.

• The Project is represented by its co-ordinators and Community HealthWorkers and participates on a range of national and regional advisorycommittees and working groups:

• At national level there is representation on: the National Health AdvisoryCommittee and its subgroups Traveller Ethic and Research InformationWorking Group (TERIWIG), the Ethic Working Group, the Ethnic IdentifierWorking Group, National Traveller Health Status and Needs AssessmentWorking Group and the Traveller Consanguinity Working Group. It alsoresources and participates in the National Traveller Health Network.

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• At regional level the project is represented on the ERHA Traveller Health Unitand the Eastern Regional Traveller Health Network.

• At local level, there is representation in the recently set up Traveller AreaHealth Committee in Community Care Area 6.

• Regular seminars, conferences, roundtables and workshops are organisedwith health service providers and policy makers to highlight the situation ofTravellers health and to create a space to discuss challenges andmechanisms to address these issues with a view to increasing equality ofoutcome for Travellers in relation to their health status.

10. National networking and support to Traveller Health projects nationally

As a response to a demand for information and support from the PHC project inPavee Point by the Traveller organisations around the country, a number of steps/supports were put in place.

• Regular workshops/ training days were provided to orientate new co-ordinators.

• The PHC project, responded to requests around the country to makepresentations on its history and development to support the establishment ofPHC projects in other areas. Health team members have responded torequests to become technical advisers on steering committees for PrimaryCare projects around the country.

• Due to demand for specific technical support to PHC co-ordinators, and theconcern that projects were beginning to replicate the outcomes of the projectsand not the process, Pavee Point developed a Primary Care Trainers TrainingCourse for PHC Co-ordinators, based on the experience of the PHC projectdevelopment and accredited at Post Graduate Certificate level by the EqualityStudies Centre in UCD. The course was developed to train co-ordinators tofacilitate the replication of the Primary Health Care for Traveller projectsnationally. The course was designed in recognition of the fact that the projectco-ordinators were from both Community Development and health servicebackgrounds, therefore a shared analysis needed to be developed. Thecourse participants of the first course were existing or potential co-ordinatorsof the PHC projects i.e. Community Workers from Traveller organisations,including one Traveller CHW, and public health nurses from the Health Boardsfrom around the country.

• A National Traveller Health Network, which is resourced by the health team inPavee Point was established for all Traveller organisations, interested indeveloping a health agenda. Initially there were 20 members, this hasincreased to approx. 70 members, from Traveller projects all over Ireland asthe number of PHC projects and funding opportunities have increased. Thenetwork meets about 7 times a year, the Irish Traveller Movement and NationalTraveller Women’s Forum are members of this network and it is used as amechanism for the national Traveller organisation representatives on theNational Traveller Health Advisory Committee (NTHAC) to give feedback ondevelopments at National level and to get information to feed into the nationalcommittees.

• Due to the expertise that Pavee Point has developed in health at local,regional and national level, the Department of Health funded the health teamin 2003, to assist them with the implementation of the National Traveller HealthStrategy. This has allowed Pavee Point to get involved in and facilitate anumber of new initiatives. This has resulted in more regional support, atraining needs assessment has been completed and a number of trainingworkshops and materials and information were developed to prepare theTraveller organisations for the consultation process for the new NationalTraveller Health Status and Needs Assessment Study; a video has been madeon the National Traveller Health Strategy; participation in the design andtraining of staff for the ‘ethnic identifier pilot project’ has also been facilitated.

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Outcomes from the perspective of the Traveller Community• The Project has been highly successful in establishing Primary Health Care

service delivery by Travellers to Travellers.

• The Project has won 2 major awards: a WHO award in 1998 for communityparticipation and a Guinness Living in Dublin Award 2001 for CommunityDevelopment.

• In the Community Care Area 6, accredited training for 16 Traveller women asCommunity Health Workers was provided and the Project demonstrated asuccessful model of employment for Travellers in health care provisions. Thetraining is a continuous and dynamic process, new competencies, skills andknowledge are acquired as new needs are identified, in an ever evolving policycontext and as the Community Health Workers engage in a representationalrole in regional, national and international committees.

• Networking with Traveller organisations at national and local levels hasfacilitated the passing on of information and resources on the health issuesfacing Travellers and has promoted and facilitated the desire for the extensionof the Primary Health Care Programme. There is a growing realisation of thepotential of health initiatives among the Traveller community.

• The provision of in-service training to a range of health professionals aims toencourage health personnel to offer a more culturally appropriate services,and work towards an increase in the utilisation of essential services. Thetraining provided by the CHWs challenges racism and discrimination at bothindividual and institutional level.

• Presentations have been made at a number of local, regional, national andinternational conferences.

• The Project has been replicated and there are now 28 Traveller Primary HealthProjects in existence throughout the country and it is recommended as amodel of good practice by the National Traveller Health Strategy.

• The process of facilitating community participation in the project has resultedin the empowerment of Travellers and led to them taking more control of theirhealth needs. Attitudes to the health system has changed, through theprovision of information, training and resources. This in turn has brought abouta change in their ability to access the system. Travellers are making greaterdemands on the health services and have greater expectations for the healthservices to be provided in culturally appropriate ways.

• The success and impact of the Project to date has enhanced Travellerconfidence and confidence of Traveller organisations in their ability to impacton policy development and in securing better equality outcomes for Travellers.There is pride in the professional service that is being provided by theCommunity Health Workers, they are role models for other Travellers and thePHC Project provides a vision of what is possible for the next generation ofTravellers.

Community Health Workers

• CHWs are employed by Traveller organisations, this allows them to work in asafe environment, where they can continue to challenge and be challengedand develop their skills in an ongoing way. They are not employed solely todeliver a service, their remit is much broader than that, it is as much about theability to influence national policy development and the social determinants oftheir health status as it is about delivering health education messages locally.

• CHWs within projects are given as much opportunity to develop their skills andeducation as they want, some CHWs have taken subjects at Junior andLeaving Certificate level, some have trained to be literacy tutors, some havegot FETAC certification and some have done advanced computer courses.Opportunities also exist for promotion to supervisor, assistant co-ordinator, orco-ordinator posts within the project.

• One of the CHWs participated in the Trainers training course, which allowedher to be accepted for the post-graduate diploma in Equality Studies, whichmay then lead her to undertaking her Masters.

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• Two of the CHWs have been promoted to posts on the National SupportProgramme within Pavee Point.

• Development opportunities arise and come up in other programmes for thosewho have trained as CHWs. Two CHWs have moved on to develop a newprogramme on ‘Women and Violence’, another moved on to support thedevelopment of an initiative on addiction. Others have moved out of the areaand brought their experience and expertise with them to other organisations orPHC projects. Another two CHWs now work as crèche workers within thesettled community, another is employed as a home help.

• Due to the fact that the project targets women who prefer to work part-timebecause of child care commitments, it was deemed necessary to facilitate thisby allowing women to work at rates of pay, which did not infringe upon theirwelfare payment and secondary benefits, particularly their medical card whichis invaluable. To make the job attractive, and once training is completed, hoursof work are decreased in order to maintain a generous hourly rate. The projectfeels if it tried to give CHWs parity with other health care staff, they would runthe risk of losing their secondary benefits and this could not be compensatedfor. The Project has approached the Department of Social Welfare to seeksupport for a scheme which would make it more attractive for Travellers tomove from welfare to work without loss of secondary benefits.

• As the numbers of qualified CHWs increases in the country, the Project isexploring the possibility of supporting CHWs to establish a professional bodyto look after their professional interests, development and remuneration.

Challenges being addressed by the ProjectDue to the increase in the numbers of members in the National Traveller HealthNetwork, and the demand to support representatives on regional Traveller HealthUnits (THUs) it has become difficult to effectively discuss and resolve all thecurrent issues arising in the work, particularly with the challenges in implementingthe NTHS. Pavee Point are now planning to work with regional Traveller HealthNetworks and deliver training and support at regional level. National meetings willbe held twice yearly. There are some very well established networks like the ERTHin the Eastern region, there is also one in the Western Health Board region.

There is a need for ongoing support and for specific technical support to PHC co-ordinators given the expansion of the work in new locations. However there is anurgent need to ensure a clarity of purpose and clarity in the understanding of theCommunity Work focus and the Community Work principles that have beenfundamental to the success of the work to date. There is a concern that as thenumber of projects expands, some are beginning to replicate the outcomes of theProject and not the process. The Community Work practice needs to bestrengthened and supported.

Ensuring the recognition of CHWs as professional workers poses particularchallenges and raises equality issues for the Project. The role of the CHW needsto be fully appreciated. The Project acknowledges that opportunities need to beprovided for CHWs to acquire qualifications and credentials, for those who wish towork both on a part-time and a full-time basis, and to allow them to be properlyremunerated and with real opportunities to move from welfare to work.

The standardisation of training courses delivered to CHWs nationally and thedevelopment of an agreed system of external evaluation and accreditation of thattraining has also been the focus of attention of the Project for some time. Currentlythere are discussions taking place between FÁS, Pavee Point and the Departmentof Health and Children to agree funding the development of ‘core curriculum’ andaccreditation of training for CHWs nationally.

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Lessons from the Project to dateMuch work still needs to be done in terms of improving the health of theTraveller community. The Primary Health Care Project has made a significantcontribution to improving health service delivery to Travellers, but given the natureof the health problems that Travellers face, a variety of responses are needed tothe variety of difficulties and problems that Travellers face within and beyond thehealth service. The Traveller Health Strategy is an acknowledgement of this fact.Traveller organisations and the Community Health Workers are in no doubthowever that unless there is a concerted effort to address the social, economicand environmental determinants of Traveller health, real health gain and healthoutcomes cannot be realised. For Pavee Point, while the Traveller Primary HealthCare Project has demonstrated a model of health service delivery to Travellers, itis an integral and an integrated element in its overall work to attain civil, political,economic, social and cultural rights for Travellers.

The Community Work Approach has been Key to the success of the PrimaryHealth Care Project. A Community Work approach focuses on social change andsocial justice for those experiencing social exclusion. Such an approach:

• is based on a set of Community Work principles that involve not only buildingcapacity to participate, but also the development of consciousness, analysisand understanding of the issues to be addressed.

• focuses on how things get done as well as what needs to get done in waysthat are empowering for all concerned, particularly the Travellers. It focuses onpower sharing.

• works to develop a collective understanding of concerns and issues, to workcollectively and above all to achieve collective outcomes for the Travellercommunity.

The approach and the set of Community Work principles underpinned the designof the Project. The long-lead in the Project was crucial. It allowed sufficient timeand resources to enable the women to develop the personal and technical skills(confidence, teamwork, communications and analysis) which are core to theProject implementation. The fact that key elements of the pre-training are theinformed insights into Traveller health issues means that Traveller organisationsmust play a core role in this training.

The principles continue to guide and underpin the research, the analysis, thenetworking, the advocacy and lobbying work.

The principles were applied to the rules of engagement in the partnershiparrangements with the Health Boards and the State Agencies and GovernmentDepartments - especially in the expectation and the assertion of the right todialogue as equals while respecting each others roles, responsibilities and ethos.Mutual respect for the different perspectives represented a core principle of theoperation of the Primary Health Care Project.

The Traveller Primary Health care model has been widely identified as aparticularly useful one that has now been mainstreamed across all Health Boards.The ability to lobby nationally has been seen as a crucial factor in thismainstreaming process.

The Primary Health Care Project model has been an inspiration to other NGOsand organisations working with excluded and marginalised groups, the principleshave been taken on board and elements of the Project have been transferred andreplicated in other areas and with other target groups. Replication of the projectmust be based on the application of the principles, not the outcomes of theproject.

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The role of Community Health Workers needs to be carefully defined in theservice delivery model to ensure equality outcomes. Serious considerationneeds to be given by the community groups and organisations who choose toengage in service delivery for the state to: the terms and conditions of employmentof Local Community Health Workers, to their career path options, to how theirpersonal and professional development needs will be met.

For Further Information ContactBrigid QuirkeCo-ordinatorTraveller Health ProjectPavee PointNorth Great Charles StreetDublin 1Phone 01 8780255email [email protected]

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Key Actions� Development of a model of Traveller participation in the promotion of

health#� Establishing a partnership arrangement" based on parity of esteem between

the partners� Targeted initiatives#� Development of culturally appropriate materials" programme approach and

methodology#� In!service training for those in the management and the delivery of the

programme#� Promotion of Traveller health needs and the social determinants of health#� Influencing the policy context#� Research" data collection" publication of reports#� Lobbying#� Advocacy#� Regional" national and international networking# Promotion of the model#

Enhancing solidarity with other groups experiencing inequality#� Regional and national networking and support to Traveller Health Projects

Elements of Good Practice � Strategically focused� Clear community work" equality and human rights perspective underpins all

aspects of the work#� Project developed as a partnership based on clear commitment to dialogue"

to equality" and on a mutual respect for the contribution and expertise thateach partner would bring to the partnership#

� Travellers define the priorities for their community#� Social model of health was the perspective adopted from the outset#� Starting point is solidarity" locally" nationally and internationally� Focus of the Project is on:

#Equality outcomes for the Traveller community# Influencing policy#Building the capacity of others to expand the model and develop

appropriate responses in new areas#Emphasis on research" analysis" evaluation and documentation of

the issues which empowers and supports the Projects lobbying andadvocacy work#

Challenges� Continuing to raise the health status of Travellers� Ensuring a community work focus in the health projects as they expand in

number under the Traveller Health Strategy# Ensuring that they are guidedby" and work from a community work" equality and a human rightsperspective# Maintaining an emphasis on the process as well as the outcomesof Projects

� Standardisation of training and the core curriculum for CHWs� Ensuring the recognition of Community Health Workers as professional

workers" with career paths" ample opportunities for acquiring qualificationsand credentials and remuneration#

� Providing support to the increasing number of members of the NationalTraveller Health Network" and meeting the demand to supportrepresentatives on regional Traveller Health Units in ways that will facilitatean exchange of experience" ideas" and analysis in order to promote goodpractice and influence and contribute to policy formulation locally"regionally" nationally and internationally#

Should Community Development Projects beengaged in the delivery of Health Services andHealth Projects?The ultimate goal for Community Development workers, Community Developmentprojects and the community sector, is structural change which results in a moreequal and healthy society and the highest standards and quality of health serviceprovision that can be accessed on the basis of need, not on one’s ability to pay. Itdoes not mean or imply that a Community Development project or the communitysector engages in the provision or the delivery of health services.

The role of the Community Worker and Community Development project doesimply however that they:

• build organisation,

• develop an understanding of the relationship between poverty, inequality andsocial inclusion and provide a context within which local communities canrelate and examine their experiences to a structural analysis of poverty,inequality and social exclusion

• enable marginalised communities to explore and identify their health needsand to develop their own health agenda, and facilitate the development ofconsciousness, analysis and understanding of the issues to be addressedwithin policy and decision-making arenas,

• strengthen the voice of marginalised groups, and their skills, knowledge andcompetence to negotiate, to advocate for social change, and to impact ondecision-making and on policy development

• ensure that the health of the communities with whom they work isacknowledged as a complete sense of physical, mental and social well-beingand not merely the absence of disease or infirmity, and that the that health isa resource for everyday life.

Many community groups are invited and encouraged to engage in healthpartnership arrangements, to become involved in community based healthpromotion initiatives, to be seen to be committed to achieving the NationalAnti-Poverty Strategy (NAPS) health targets.

It is important to be strategic when making decisions. Experience to date suggeststhat community groups should be very clear, and should have considered andagreed their objectives and their own agenda before embarking on a healthpromotion initiative or before becoming involved in the development of a healthservice project which they have not fully designed, negotiated, or proposed.Community groups can be tempted to engage in initiatives, or to refocus their ownpractice in order to get their hands on much needed resources.

Good practice would also imply that they should also be very clear and agreed ontheir own objectives and their own agenda before entering into a formalpartnership arrangement to deliver a health service. The community group needsto acknowledge that unless it has formally negotiated and agreed the objectives,methodology and expected outcomes of the partnership project, it is of coursecommitting itself and is obliged to deliver the agenda of the proposedproject/partnership.

The role of Community Health Workers needs to be carefully defined in theservice delivery model to ensure equality outcomes.

Community Health work can be considered low-paid service work and thisprovides an equality challenge for (a) the workers - in the main women, (b) theorganisations engaging in the service delivery, (c) the community to whom theservices are delivered and (d) the community sector that advocates for the higheststandard of service delivery to already deprived communities. *&


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Inequalities can be generated and reproduced when local community healthworkers are not respected for the experience and expertise they have acquired,and for their commitment and work in advancing the health and well-being of theircommunities.

At the same time, inequalities are generated for the workers and theircommunities, if they are not facilitated as part of their employment to acquire theskills and knowledge and the credentials that would enable and allow them to haveequality outcomes from employment opportunities and to provide quality healthservices to their communities in community based health initiatives.

Serious consideration needs to be given by the community groups andorganisations who choose to engage in service delivery for the state to: the termsand conditions of employment of Local Community Health Workers; to their careerpath options; to how their personal and professional development needs will bemet.

When considering engagement in health service provision or in theimplementation of a health project, it may be helpful to pose and answer anumber of questions with the local community group or Community Workproject. e.g.

"Is this what is good for the community and for the people with whom we work?Is investing energies in the project the most appropriate way to achieve ourobjectives and advance our agenda?

"Is the initiative guided by Community Work principles, what are the expectedequality outcomes for the community and groups? Is this good CommunityWork practice?

"How much is the possibility of accessing additional, and much neededresources influencing the decision to get involved? Has the agenda, or theproject being proposed already been defined as a priority with the mostmarginalised and excluded groups locally? Would it be considered a prioritystrategically for the Community Work practice?

"If the community group is not clear about the value of the project as proposedand does not have a 100% commitment to the project or partnershiparrangement as outlined, is it confident that it can successfully negotiatechanges in the focus of the proposed project and /or partnershiparrangement? and, that the lead agency is open to its proposal beinginfluenced and changed? What is and how much is negotiable?

"Will the resources available for the project be sufficient to develop and sustainthe initiative and make an impact? Will a shortfall in resources to implementthe project mean that existing limited human and financial resources alreadyallocated to the community projects work will need to be re-deployed? Is thisreally in the interests of the community group or project. Is this the mostappropriate way to achieve our objectives and advance our agenda?

"If local Community Health Workers are to be employed has enoughconsideration been given to the terms and conditions of their employment?to their career path options? to how their personal and professionaldevelopment needs will be met?

Some projects having made an assessment of the potential and the expectedhealth outcomes of a proposed initiative have either engaged wholeheartedly orchosen to re-focus their work.

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�We were really keen toincorporate a health agenda inour work locally# We did aneeds assessment" we fed backthe findings and held anumber of workshops in thelocal community to getagreement on the wayforward# We put a proposal toour health board for supportto employ a CommunityDevelopment worker to helpthe community to develop itshealth agenda within thesocial model of health#Needless to say we were verydisappointed when the healthboard would only support thehealth board�s employment ofa community health worker"with a clearly pre!defined andnarrowly focused healthpromotion brief# The worker is grand" is veryenthusiastic" but has noexperience in CommunityWork approaches or inCommunity Development# Itreally limits what is nowpossible# More serious thanthat though is the fact thatthere is no developmentalprocess and we are carrying aworker and an agenda that wenever really wanted�#(Workshop participant" andco!ordinator of a local CDPProject)

Good Practice implies ...

• Clarity of vision (definition of health and well-being, understanding of thesocial, economic and environmental determinants of health, a rights basedapproach to the highest standard and quality health service)

• Analysis of needs, with an underpinning analysis of the causes of poverty,inequality and social exclusion

• A strong policy agenda that is based on identified need, where there is strongownership and where it is developed independently of the state

• Commitment and ability to advocate and lobby, to negotiate change andengage in policy, decision-making and partnership processes

• Connections and networks between the community sector, locally, regionallyand nationally that can link experience, deepen analysis and strengthen thecommunity sector.

Meaningful partnership arrangements or good working relationships withthe statutory sector implies:

• That those mandated by the community group / community sector to representtheir interests at the partnership board, are acknowledged for their expertise,skills and experience in the area of social inclusion and equality and theempowerment of the most excluded communities to engage with processesand decision-making that impacts on their lives.

• That the community sector is adequately resourced for its advocacy role, andto enable the sector to develop its own agenda and to strengthen its capacityto advance its own policy positions within the partnership structure.

• There is parity of esteem for the partners.

• The partnership arrangement is transparent in its operational andorganisational procedures and practices, that it develops an equality policy,codes of practice and a set of principles that guide and underpin its work andto which to which its partners are held accountable.

• There is an acknowledgement that partnership is a difficult, complex andchallenging relationship because it brings together people and organisationswith different backgrounds, different interest and concerns. Agreeing thecollective objective can often entail a process of negotiation. Delivering on thecollective objective implies a pooling of resources to achieve the agreedcollective objective, and a commitment to adopting a collective approach anda collective process, which will lead to a collective outcome.

• All partners in the process should engage in a process to enhance theirunderstanding and appreciation of their role in the partnership process, todevelop an appreciation of the culture of partnership, to explore and addressissues that may arise in the management and implementation of partnershipinitiatives, and to enhance skills and understanding that will maximise thepotential of the partnership to impact on policy development, locally, regionallyand nationally.

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�I feel we got really distractedaway from the real health

issues ! income" facilities for allages but especially the youngpeople" education" decent and

meaningful jobs for womenand men in this area" decent

housing and quality healthservices for people in the

community when they are ill#There is no point in cutting the

Community DevelopmentProject funding and then

pushing health promotion# Itjust doesn�t make sense�

(Health Workshop participant)

Facilitating Local Communities to developtheir Health Agenda - A ChecklistPromoting the social model of health and enhancing understanding of whatdetermines health and well-being

#Is my work to address health inequalities in the community or group with whomI work linked to my Community Work agenda? Am I aware of the healthoutcomes of the Community Work that I am currently engaged in?

#Am I aware of the social, economic, and environmental determinants of health?Do I acknowledge and promote the achievement of health and well-being as abasic human right?

#Am I enabling the community with whom I work, to develop its understandingand analysis of how inequality is generated and sustained in Irish society andhow inequality impacts on health and well-being, particularly in the mostmarginalised communities?

#Am I promoting discussion on health inequalities in the local CommunityPlatform / Equality Network?

#Am I promoting the equality proofing of all health initiatives and the healthproofing and equality proofing of all social and economic development plansand resource allocations that impact on the community with whom I work?

Facilitating the community to develop its health agenda

#Am I exploring the social model of health with the community with whom I workand enabling them to• develop a vision of what a more equal and healthy community would look like

in five years time

• define the health and well-being needs of the community that require to beaddressed

• define the communities health agenda and agree priorities for action

• explore where the communities health agenda can be taken to be addressede.g. the Local Development Partnership, the County or City DevelopmentBoard (CDB), the Social Inclusion Measures Group (SIMs), the StrategicPolicy Committees (SPCs)

#If a health initiative is being planned by the health board am I• aware of the initiative, its objectives and expected outcomes?

• ensuring that resources are being allocated to resource the local communityto define and analyse its own needs and priorities with regard to any proposedhealth initiative?

• ensuring that adequate resources are made available to develop knowledge,skills and capacity of marginalised groups to effectively engage in anypartnership process and to resource community participation in the planning,decision-making, management and review of the health initiative?

• ensuring that any partnership arrangement that engages the community,formally adopts the social model of health, an equality policy, code of practiceand agreed principles that will underpin and guide the operation and day today workings of the partnership and its programmes/initiatives?

Contributing to policy formulation and policy implementation

#Am I promoting equality proofing of all health initiatives and the equality proofingand health proofing of local development initiatives?

#Am I ensuring that the findings of any local research and the health agenda ofthe communities with whom I work are brought and presented to the appropriateagencies and inter-agency partnership arrangements, where they can bediscussed and shape appropriate responses to the needs identified?

#Am I developing links between the, for example, local Project, CommunityPlatform and the National Community Platform to develop and deepen theunderstanding and analysis of health inequalities and collective strategies thatwill ensure greater equality outcomes and health gain for particularlymarginalised communities?

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Best Practice Guidelines for Community-basedHealth Workers and other Health Workerswithin Statutory Agencies

Communities must be included in decisions that effect their well-being (Lessonsdrawn from practice to date in projects).

1. Part of the problem that communities suffer is that they are excludedfrom an active and meaningful involvement in influencing decisions thataffect their well-being. Health workers, and those in the statutory sector need to get a commitmentfrom the top of their organisation or agency that they will be supported toactively engage the community in the project or initiative. They needcommitment that

• The community will be engaged at all levels in the decision-makingstructures of the project.

• An individual(s) will be named who has responsibility for leading on thedevelopment of the community involvement.

• There will be clarity on the purpose of community involvement, i.e. acollaboration with the intention of tackling health inequalities and promotingequality.

• Health workers and the locally based health care professionals will bemandated to work with local communities agendas around health.

2. Adequate ResourcesAddressing inequalities must ensure that the voices and the experiences ofthe most marginalised communities are heard - geographic communities andcommunities of interest, and that the needs of these communities and theiranalysis of solutions are central to the process of designing, developing,implementing and monitoring the health care service and new initiatives.Resources must therefore be provided

• To support existing Community Development organisations to develop theirown health agenda as part of their core work.

• To support and resource particularly marginalised groups e.g. ethnicminority groups, to identify and articulate their needs, and to build theircapacity to engage in decision-making fora to develop responses to theneeds identified.

• To support the advocacy role of the Community Development projects andlocal equality networks and to strengthen their capacity to advance theirown policy positions within intersectoral partnership arrangements.

• To enable the participation of particularly marginalised groups will requirethat participation is enabled childcare, interpretation, transport.

• To build community infrastructure using a Community Work approach whichcan sustain the work.

3. The development of real and meaningful Partnership arrangementsdemands a long-term commitment.

• Partnerships should develop and outline their own equality policy, codes ofpractice and set of principles that will underpin the work of the partnership.

• Developing relationships with marginalised communities takes time andtrust must be developed.

• Effective community participation comes about through a period ofCommunity Development.

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4. The health sector must be mindful of the determinants of health and

• Promote health proofing of all social and economic and environmentaldevelopment plans and influence investments in other sectors.

• Promote and support interventions that address health in an integrated wayand positive actions targeted on reducing health inequalities.

• Equality proof all health initiatives, Primary Care Initiatives.

5. The health sector is mandated by the WHO Ottawa Charter for HealthPromotionThe National Health Promotion Strategy 2002-2005 is premised on this WHOCharter and sets out the broad policy framework within which action can becarried out by the health sector. While health promotion programmes may bedesigned locally to promote healthy eating or to encourage people to be moreactive, it must be remembered that the Ottawa Charter calls for action on fivefronts Building Health Policy; Re-orienting the health services; Creatingsupportive environments; Strengthening Community Action; Developingpersonal skills. Community - based health workers are therefore mandatedand have responsibility to promote action on all five fronts.

6. State Agencies and Department of Health and ChildrenState Agencies and Department of Health and Children must be lobbied by thehealth sector itself, to adopt a human rights framework in health policy andservice delivery in line with Ireland’s legally binding obligations under theInternational Covenant on Economic, Social and Cultural Rights, and toensure that there is an equivalence with regard to health protection and humanrights North and South in line with the Good Friday Agreement 1998, anotherinternational legally binding agreement signed by the Irish Government.

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Am I Adopting a Community Work Approachwithin the Health Project?A Checklist for health workers whose work is focused on localcommunities or communities of interest or who are employedin local community settingsIn my work ...

#Am I being guided by, and operating out of the set of Community Workprinciples?

#Am I focused on addressing inequality, poverty and social exclusion andpromoting equality, human rights and social inclusion?

#Am I adopting a collective approach to change as opposed to a focus on theindividual?

#Is my starting point the local communities’ health priorities? Am I working withtheir agenda and facilitating their collective action on that agenda?

#Am I concerned with issues of power and empowerment and relationshipsbetween decision makers and users of services?

#Am I advocating that positive outcomes are only possible when structuresand decision-making processes are appropriate and are based on equality ofparticipation?

#Am I promoting real and meaningful partnership arrangements between thelocal community and state agencies i.e. partnership arrangements that arebased on real dialogue, that facilitate mutual learning and mutualunderstanding through the sharing of knowledge and expertise of each of thepartners in relation to health inequalities and the sharing and discussion ofideas on potential solutions?

#Am I supporting participatory research in the community and gathering andcollating the evidence presented from social, economic and environmentalfactors locally, not just lifestyle behaviour and illness patterns so as to ensurehealth and social gain for particularly marginalised communities?

#Am I taking on a leadership role, taking responsibility for promoting integratedapproaches in the development of policy and practice within the healthservice? Am I engaging with others to draw lessons from the implementationof the National Health Promotion Strategy to date, in order to influence theorientation of future health promotion strategies?

#Am I actively promoting inter-sectoral and multi-sectoral approaches thatfocus on the social and economic determinants of health in order to addressthe causes of health inequalities? or am I stuck and confining myself to myown agency’s ‘patch’ and remaining narrowly focused on the health targetsof the agency with whom I work?

Am I effectively engaged and focused on the development ofopportunities for the most marginalised groups andcommunities to effect change ?Am I facilitating ...

#their identification and social analysis of health and well-being needs, theiridentification of health priorities and of the most appropriate responses topromote greater health and well-being appropriate responses?

#the development of their self esteem?

#the development of consciousness, analysis and understanding of the issuesto be addressed so that they can take part in collective action?

#the strengthening of their organisational capability in order to enable andfacilitate them to influence decision-making in relation to their health andwell-being and enable them to impact on local and national policy ?

#linking the health work and the communities health agenda into otheragendas for social and economic development and for social change at locallevel. Am I promoting the incorporation of the community’s health agenda intothe agenda of RAPID, the Local Development Partnership, the SocialInclusion Measures Group (SIMs) and the Strategic Policy Committees of theCounty Development Board?

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How do we know that Community Involvementis successfulA checklist for the Statutory Agencies and Local HealthWorkers(The checklist was first presented in Delivering Health in the New NHS: the role of thePublic. A Discussion Paper Community Action on Health, Newcastle Upon Tyne. Autumn2000. Author Philip Crowley)

The checklist helps assess the relevance of the health project to the localcommunity and outlines success criteria for judging community participation (andthe relevance) in the Health Initiative / Project.

Is there:

"Evidence of minority group involvement (race34, gender, sexuality,disability)35

"Clear working class focus and input (not middle class people speaking forworking class community participants)

"Evolving community leadership, personal development and confidencefor community participants

"Evidence that the communities agendas are being pursued

"Evidence of community impact on decision-making or on policy

"Evidence that working in partnership with the community has become thenorm across all the local system’s way of working (Organisationaldevelopment)

"Evidence that it is properly resourced

"Evidence that there is some shift from the medical model to the socialmodel of health

"Practice and policy that is to some degree directed at the root causes ofill health not the symptoms

"That individuals that represent their community are not isolated but aresupported to be linked to and be accountable to a wide communitynetwork

"There is clear focus on inequality and redistribution of resources

"Evidence that discrimination is being highlighted and challenged

"Successful work should be evidently challenging to the system

"There should be evidence that the health service and its professionalsare being called to account

"Evidence that links are being created between communities

What is most interesting about the checklist is how easily values, principles andgood practice transcend national or local boundaries.

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%$ We need to also acknowledge difference and diversity in relation to ethnicity" ethnicor national origin" skin colour" membership of the Traveller community" differencesin cultural or religious beliefs and practices#

%& Given the equality focus of community development work" older people" andhomeless people or their organisations" would also be included in this classificationof minority group given the extent of their exclusion from social" economic andcultural life#

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APPENDIXESAPPENDIXES

APPENDIXES

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AAppppeennddiixx IIQuality and Fairness - A Health System for You

A brief overview of the key elements of the National Health Strategy

The National Health Strategy Quality and Fairness - A Health System for You

• focuses on health, not just on health services

• acknowledges that peoples health is affected by socio-economic,environmental and cultural factors

• emphasises the non-medical aspects of achieving full health and recognisesthe formal and informal role of the community in improving and sustainingsocial well-being in society

• views health expenditure as an investment, both for the social value ofimproved health and well-being but also for its ‘direct economic benefits’including lower absenteeism, greater life expectancy thus a longer span ofproductive working life in the formal economy or care work.

The Strategy is underpinned by four key principles:

• Equity

• People-Centredness

• Quality

• Accountability.

The four goals of the Strategy are

• Better access for everyone

• Fair access

• Responsive and appropriate care delivery

• High performance

However the Concluding Observations of the Committee on Economic, Social andCultural Rights in May 2002 stated:“The Committee notes with regret that a human rights framework encompassing,inter alia, the principles of non-discrimination and equal access to health facilitiesand services, as outlined in paragraph 54 of the Committee’s General CommentNo. 14 on the right to health, was not embodied in the recently published NationalHealth Strategy. The committee also regrets the State parties failure to introducea common waiting list for treatment in publicly funded hospital services for publiclyand privately insured persons”.

The Committee recommended in May 2002 that Ireland review the National HealthStrategy with a review to embracing a human rights framework in the strategy inline with the principles of non-discrimination and equal access to health facilitiesand services. The Committee furthermore urged the State to introduce a commonwaiting list for treatment in publicly funded hospitals for privately and publiclyinsured patients.

Contrary to the recommendations of the UN Committee on the InternationalCovenant on Economic, Social and Cultural Rights, and in spite of the ongoingdemands of the community sector, the government refused to adopt a humanrights approach to the Health Strategy.

The National Health Strategy

Strengthening Primary Care is one of the six Frameworks for Changeoutlined in the Health Strategy.The Strategy (Chap 5 p.93) defines the function and the role of Primary Care:“It is concerned with developing a properly integrated system, capable ofdelivering the full range of health and personal social services, appropriate to thissetting. Primary care must become the central focus of the health system so thatit can help achieve better outcomes and better health status”.

Ten Pilot Primary Care Projects were approved in October 2002“The government is committed within resource constraints, to advancing theimplementation of the Strategy Primary Care: A New Direction’”

Commitment to Community ParticipationThe National Health Strategy contained a specific commitment to communityparticipation and stated that “provision will be made for the participation of thecommunity in decisions about the delivery of health and personal services” (Action52).

Community Participation Guidelines were published by the Health BoardsExecutive in 2002. The guidelines are to be used by all health service providers toensure that the principle of ‘people-centredness’ which is at the heart of thestrategy becomes an increasingly important feature of how services are plannedand delivered.

The concept and practice of community participation in the Health StrategyImplementation Project is clearly defined on page 3.Community participation can be defined as“A process by which people are enabled to become actively and genuinelyinvolved in defining the issues of concern to them, in making decisions aboutfactors that affect their lives in formulating and implementing policies, in planning,developing and delivering services and in taking action to achieve change”.

In Section 5 Framework for Participation, the guidelines state “The aim of thehealth services in Ireland should be to move the level of community participation.. from mere consultation to actual involvement in determining priorities, assessinglocal needs, and decision-making. Central to this issue is CommunityDevelopment in relation to health matters, leading to empowerment ofcommunities” (p.6).

However for the purpose of engagement the term ‘Community’ is clearly focusedon the traditional ‘consumer’ model rather than on the model of participation andsocial partnership that has been at the centre of social policy for the past 15 yearsand that has supported social inclusion and equality. The proposed framework forsocial partnership which purports to be based on the people-centredness principleof the Health Strategy seeks to draw upon and be concerned solely with theconsumer of market goods, the clients of health services, rather than with aconcern with social inclusion and equality i.e. the designation of spaces forwomen, minority ethnic and anti-poverty and equality groups. It is market drivenrather than driven with a concern for social inclusion and a greater democratisationof decision-making at local, regional and national level with regard to healthservice delivery.

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The structures proposed for involvement of the community are:

• Regional Advisory Panels/Co-ordinating Committee

Advisory Panels should represent the needs of individuals across thespectrum of care including those enjoying good health, in acute care andcontinuing care settings. The Advisory Panel should act as a resource toservice planners and providers, in shaping and designing services which areappropriate and acceptable to the specific community.

• Consumer Panels

Randomly selected Consumer Panels will be convened at regular intervals ineach health board area to allow the public to have a say in health matters thatconcern them locally.

With regard to membership, the guidelines state “selection should favouradvocates not aligned to special interest groups specified in the Strategy, suchas children or asylum seekers”, “Health professionals and politicalrepresentatives should not be debarred but should not be favoured either”.The guidelines also say that “efforts should be made to invite participationreflecting geographical, social and age profile of the population”.

The role and functions envisaged for the Consumer Panels are wide rangingand varied, as advisory to the board, mediatory between board and public andconsultative with the public. Possible functions for the consumer panel havebeen defined as including

#participation in board-led service reviews, as guardians of equity andaccessibility and

#assessing incoming reports and requests from the community and voluntarysector

• The National Consultative Forum

This broadly based consultative forum is to be convened annually to considerprogress reports on the implementation of the Health Strategy and to commentin the light of progress and emerging trends. There is no indication given as tothe desired membership of this forum.

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Combat Poverty AgencyBridgewater Centre, Conyngham Road, Islandbridge, Dublin 8. Tel 01 6706746 / Fax 01 6706760 / E-mail [email protected] / Url www.combatpoverty.ie

Community Development and Health Network30a Mill Street, Newry BT34 1EYTel 028 3026 4606 / Fax 028 3026 4626E-mail [email protected] / Url www.cdhn.org

Community Platformc/o Community Workers Co-operative, 1st Floor, Unit 4, Tuam Road Centre,Tuam Road, Galway. Tel 091 779030 / Fax 091 779033 / E-mail [email protected] / Url www.cwc.ie

Department of Health and ChildrenHawkins House, Hawkins Street, Dublin 2.Tel 01 6354000 / Fax 01 6354001 / E-mail [email protected] / Url www.doh.ie

Equality Authority2 Clonmel Street, Dublin 2.Tel 01 4173333 / Fax 01 4173331 / lo-call 1890245545E-mail [email protected] / Url www.equality.ie

Health Promotion UnitDepartment of Health and Children, Hawkins House, Hawkins Street, Dublin 2.Tel 01 6354000 / Fax 01 6354372 / E-mail [email protected] / Url www.healthpromotion.ie

Institute of Public Health5th Floor, Bishops Square, Redmond’s Hill, Dublin 2.Tel 01 4786300 / Fax 01 4786319 / E-mail [email protected] / Url www.publichealth.ie

Public Health Alliance5th Floor, Bishops Square, Redmond’s Hill, Dublin 2.Tel 01 4786300 / Fax 01 4786319 / E-mail [email protected] / Url www.publichealthallianceireland.org

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AAppppeennddiixx IIII UsefulContacts

A Strategic Policy Framework for Equality Issues. Report No 23. NationalEconomic and Social Forum, 2002.

Early School Leavers. Report No 24. National Economic and SocialForum, 2002.

Housing Statistics Bulletin. Department of the Environment. September2002

Income, Deprivation and Well-being among Older Irish People. Economicand Social Research Institute, 1999.

Irish Politics - Jobs for the Boys. National Women’s Council of Ireland,2002

Mental Illness - The Neglected Quarter. Amnesty International Ireland,2003

Monitoring Poverty Trends and Exploring Poverty Dynamics in Ireland.Economic and Social Research Institute, 2001.

Monitoring Poverty Trends in Ireland: Results from the 2000 Living inIreland Survey. Policy Research Series No. 45. Economic and SocialResearch Institute, 2002.

National Health Promotion Strategy 2000-2005. Department of Healthand Children, 2000.

Poverty and Health: evidence and action in WHO’s European Region.World Health Organisation Regional Office for Europe, 2001.

Poverty in Ireland: Data from the 2000 Living in Ireland Survey. PovertyBriefing No 13. Combat Poverty Agency, 2003

Report of the Working Group on the National Anti-Poverty Strategy andHealth 2001. Institute of Public Health.

Rights and Justice Work in Ireland: A new baseline. Brian Harvey. TheRowntree Charitable Trust, 2002.

Study of the Gender Pay Gap at Sectoral Level in Ireland. Reportprepared for the PPF Consultative Group on Male/Female WageDifferentials. INDECON International Economic Consultants, 2002.

The European Health Report 2002. Regional Publications No. 97. WorldHealth Organisation 2003.

Unhealthy Societies: The Afflictions of Inequalities. Richard G. Wilkinson.Routledge, 1996.

World Development Report. United Nations Development Programme,2002.

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Appendix IIIBibliography

Other Publications of the Community Workers Co-operative

Building Sustainable Communities: Community Participation in the RAPID ProgrammeThis publication outlines the negotiation of the RAPID programme in 1999through to its current implementation and documents the experience of five localanti-poverty organisations in engaging in the RAPID process since it came onstream.

2003 / € 7.00

Developing Methodologies and Strategies to Combat Social Exclusion Documents the efforts of NGOs and local authorities in four EU membercountries to develop local social inclusion strategies and lays down a foundationto further develop this important area.

2001 / € 5.00

Equalising Outcomes in EducationUsing community development approaches to tackle educational inequality.

2002 € 3.00

Organising for ChangeA handbook for women participating in local social partnership.

2003 free

Strategies for Mainstreaming (Strategy Guide No. 5)A series of case studies outlining practical actions taken to mainstream equality.

2000 / € 5.00

Strategies for Social Partnership (Strategy Guide No. 6)Experiences, lessons and insights to guide the development and practice of local& national social partnership.

2001 € 5.00

Strategies to Address Educational Disadvantage (Strategy Guide No. 4)A series of case studies on how best to address educational disadvantage.

1999 / € 5.00

Strategies to Encourage Tenant Participation (Strategy Guide No. 3)A series of case studies outlining strategies and actions used to encouragetenant and resident participation.

1998 / € 5.00

Violence Against Women - An Issue For Community Work Why is violence against women an issue for community work? This publication isintended to act as a practical resource to community groups in developingappropriate responses.

1999 € 3.50

Wealth, Power, Inequality: challenges for community work in a new eraProceedings of a Community Workers’ Co-operative Conference in Kilkenny in2001.

2003 / € 7.00

For a full publications list check out www.cwc.ie or contact the Community Workers Co-operative at 091 779030 / E-mail: [email protected]

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Community WorkApproaches

to addressHealth Inequalities

This Strategy Guide is being produced by the CWC in order to highlight best practice, and to form a basisof practice guidelines for locally based workers regarding Community Work and health. The production ofthe Strategy Guide is opportune at a time of developing interest in health inequalities, and at a time when amajor restructuring of the health service is beginning to take place in line with the commitments under theNational Health Strategy 2001 Quality and Fairness - a Health System for You. The Health Strategy puts afocus on health, not just on health services and acknowledges that peoples health is affected by socio-economic, environmental and cultural factors. The Strategy which emphasises the non-medical aspects ofachieving full health and recognises the formal and informal role of the community in improving andsustaining social well-being in society, has ‘Strengthening Primary Care’ as one of its Frameworks forChange.

Health inequality refers to “the differences in the prevalence or incidence of health problems betweenindividual people of higher and lower socio economic status” (World Health Organisation 1998).

Because of the prevailing medical definition of health, Community Workers and Community Developmentinitiatives often do not recognise the health outcomes that arise from Community Work. CommunityWorkers are engaged in work that both promotes and produces good health, though they might not have aclearly defined health agenda. They work with the most marginalised groups and communities, they workto empower and enable them to identify needs and to develop confidence, knowledge and skills to workcollectively to bring about change in the central conditions of their lives. Their work is focused on buildinghealthy communities free from poverty, exclusion and discrimination. It is focused on ensuring thatmarginalised groups are enabled to move from an experience of powerlessness to a sense of well-beingand a realisation of their potential, and the realisation of their right to enjoy and fully benefit from the fruitsof social and economic development.

This Strategy Guide is produced specifically to generate an analysis of Community Work approaches tohealth inequalities at local level, to share experiences of work to date through the presentation of casestudies of Community Work approaches to addressing health inequalities. The Strategy Guide is alsointended to help develop a focus on influencing policy with a view to achieving more healthy communities.Four case studies have been chosen for inclusion in the Guide. These detailed case studies reflect the coreelements of best practice from a range of different perspectives.

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Supported by the Combat Poverty Agency as part of its Enhanced Funding forNational Networks Scheme# The views expressed in this publication are those of

the CWC and do not necessarily reflect the views of the Combat Poverty Agency#

�*#'' ISBN 0-9540765-3-2